Failure to Implement and Communicate Timely Nutritional Interventions for Residents with Significant Weight Loss
Penalty
Summary
The facility failed to implement timely and appropriate nutritional interventions, follow dietitian recommendations, update care plans for weight loss, and notify the dietitian, physician, and resident representatives of significant weight loss for three residents. For one resident with moderate cognitive impairment and pressure ulcers, significant weight loss was not reported promptly to the dietitian or physician, and care plans were not updated to address the weight loss. The resident experienced ongoing poor meal intake, and there were delays in implementing recommended nutritional supplements. Family notification of the weight loss was also delayed, and the care plan was not updated until months after the initial weight loss was documented. Another resident, also with moderate cognitive impairment and a history of congestive heart failure and fluid restriction, experienced substantial weight loss over several months. The resident's nutritional supplement orders were not implemented in a timely manner, and there was a lack of documentation that the physician was notified of the ongoing weight loss or of the resident's reported depression. The care plan did not address the weight loss, and staff were unclear about the process for updating care plans and notifying appropriate parties. A third resident, who was cognitively intact and admitted with a stage four pressure ulcer, also experienced significant weight loss. The care plan was not updated to reflect the weight loss or new interventions, and there was no documentation that the physician was notified. Recommendations from the dietitian were not implemented promptly, and the resident's food preferences were not consistently reflected in meal planning. Staff interviews revealed confusion about roles and responsibilities for monitoring, reporting, and care planning related to weight loss.