Failure to Maintain Nutritional Status and Address Significant Weight Loss
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status, specifically body weight, for two residents who experienced significant weight loss. One resident, with multiple diagnoses including muscle wasting, anemia, dysphagia, diabetes, and depression, lost 15.15% of body weight since admission. Despite triggering for significant weight loss, the care plan and interventions were not updated after the loss was identified. The resident reported not eating the provided food due to dislike and not being offered alternatives or snacks, and staff interviews confirmed a lack of new dietary interventions following the weight loss. Another resident, also with complex medical conditions such as muscle wasting, dysphagia, and GERD, lost 8.31% of body weight in just over a month. The resident was on a pureed diet and reported not liking the food, having difficulty eating due to dental issues, and not receiving adequate dietary variety. The nutrition evaluation noted the resident was not meeting estimated nutritional needs, and although a supplement was recommended, the care plan did not reflect updated interventions after the significant weight loss was discovered. The order for weekly weights, as recommended by the dietitian, was not present in the physician orders. Interviews with staff, including the DON and SLP, revealed a lack of awareness and communication regarding the residents' weight loss. The SLP was not informed of the weight loss, and the DON was unaware of the extent of the issue or the absence of weekly weight orders. The facility's policy required more frequent monitoring and interdisciplinary communication for significant weight loss, but these steps were not documented or implemented for the affected residents.