Failure to Reassess Nutritional Needs After Significant Weight Loss in Tube-Fed Resident
Penalty
Summary
The facility failed to monitor and reassess the nutritional needs of a resident who was receiving tube feeding. The resident, who had a history of muscle weakness and severe protein-calorie malnutrition, experienced a significant weight loss of 22% over a four-month period. Despite this, the registered dietitian (RD) did not reassess the resident's nutritional needs after the new, lower weight was identified. The RD continued to use an outdated weight for nutritional calculations and did not address the substantial weight loss in subsequent nutrition notes. Additionally, the RD acknowledged in an interview that monthly nutritional assessments were not completed for this resident as required by facility policy. The resident was cognitively intact and expressed confusion about the need for tube feeding, indicating a lack of understanding or agreement with the intervention. The care plan identified the resident as being at high nutritional risk and in need of maintaining nutritional intake without significant changes. Staff interviews confirmed that the resident sometimes refused tube feedings, and there was a lack of documented reassessment or adjustment of the care plan in response to the resident's ongoing weight loss and feeding refusals.