Failure to Monitor and Report Significant Weight Loss and Nutritional Decline
Penalty
Summary
A facility failed to obtain physician-ordered weekly weights and did not notify the physician or registered dietitian of a resident's repeated refusals of nutritional supplements, decreased meal consumption, and significant weight loss. The resident, who had a diagnosis of severe protein-calorie malnutrition, dementia, and type 2 diabetes with chronic kidney disease, experienced a 13.9% weight loss in less than six months. Documentation showed that weekly weights were not consistently recorded as ordered, and there was a lack of documentation regarding the amount of nutritional supplement consumed. The resident's meal intake was also inconsistently documented, with frequent low consumption and multiple meal refusals over an eleven-day period. Despite clear evidence of declining intake and significant weight loss, there was no documentation that the physician or dietitian was notified of these changes. The care plan was not revised to address the resident's rapid weight loss, decreased meal consumption, or supplement refusals until two days before the resident was hospitalized. Interviews with staff confirmed that they observed the resident's decline, including decreased activity, poor intake, and refusal to eat or drink, but did not notify the physician or dietitian as required by facility policy. The resident was eventually admitted to a hospital in a severely malnourished and dehydrated state, with diagnoses including hypernatremia, acute metabolic encephalopathy, and severe malnutrition with concern for refeeding syndrome. Hospital staff and the admitting physician noted the resident's poor condition and indicated that the decline had been ongoing for days prior to admission. Facility staff and the director of nursing confirmed that required notifications and care plan updates were not completed in a timely manner.