Failure to Recognize and Respond to Severe Weight Loss Due to Inaccurate Food Intake Monitoring
Penalty
Summary
A resident with a history of lung transplant and diabetes mellitus experienced a severe, unrecognized weight loss of 19.25 lbs. in less than a month, dropping from 92 lbs. to 72.75 lbs. Facility staff failed to accurately monitor and document the resident's food and fluid intake, resulting in discrepancies between the Weekly Summary Nurse Progress Notes and the Documentation Survey Reports. The resident's care plan required monitoring for weight loss or gain of three pounds in a week and five pounds in a month, but this was not followed. Additionally, there was no documentation of the percentage of high protein nutrition (HPN) shakes consumed, and staff did not provide clear instructions on how to calculate or record food intake percentages. The facility did not notify the resident's physician or the registered dietitian (RD) of the resident's poor dietary intake and significant weight loss, as required by facility policy and the resident's care plan. Interviews with staff revealed that CNAs estimated food and fluid intake rather than measuring it accurately, and that intake below 50% was not consistently reported to licensed nurses. The DON and DSD confirmed that if a resident's intake was less than 50% for a week or two, or if three meals were missed, the physician and RD should have been notified, but this did not occur for this resident. As a result of these failures, the resident's severe weight loss went unrecognized by facility staff, leading to a delay in care and treatment. The resident was eventually transferred to a general acute care hospital, where she was diagnosed with failure to thrive, severe electrolyte abnormalities, severe protein-calorie malnutrition, cachexia, and dehydration, and required nasogastric tube feeding. The facility did not follow its own policies and procedures for nutritional screening, assessment, and weight change protocol, which required early identification and intervention for significant weight changes.