Failure to Provide Prescribed Double Portions for Resident with Significant Weight Loss
Penalty
Summary
A resident with a history of major depressive disorder, schizophrenia, autism, anxiety, delusional disorder, and paranoid disorder experienced significant unplanned weight loss over a six-month period. Despite a registered dietician's assessment identifying a 7.5% weight loss in three months and recommending double portions at all meals, the facility failed to implement this intervention. Review of dietary tickets and direct observation confirmed that double portions were not provided, and the resident continued to lose weight, totaling a 12.5% loss in six months. The resident's nutritional assessment documented malnutrition, and progress notes indicated that the plan included double portions, staff supervision at meals, and monitoring of intake and weights. However, the dietary manager confirmed that the resident's meal tickets did not reflect the double portion order, and the dietician stated that she expected her recommendations to be followed. The facility's policy required assessment and intervention for significant weight changes, but the recommended intervention was not carried out, resulting in continued unplanned weight loss for the resident.