Failure to Monitor and Address Enteral Nutrition Intolerance and Weight Loss
Penalty
Summary
A resident with a history of esophageal laceration, gastrostomy status, and other complex medical conditions was admitted to the facility and required enteral nutrition via G-tube. The facility failed to consistently monitor the resident’s weight, with only two documented weights taken over a six-week period, despite policy requiring weekly weights for new admissions. During this time, the resident experienced a significant weight loss of 24.8 pounds, equating to an 11.98% loss, which was not promptly identified or addressed by staff. The resident repeatedly reported intolerance to the prescribed enteral nutrition, including symptoms of nausea, diarrhea, and dizziness, leading to frequent refusals of tube feedings. Although the dietitian and medical providers were intermittently notified of these issues, there was a lack of timely and coordinated reassessment of the resident’s nutritional needs. Communication breakdowns occurred between nursing staff and the dietitian, with messages not being received or acted upon, and the dietitian was unaware of key changes such as the discontinuation of supplements and the resident’s significant weight loss until weeks after they occurred. Additionally, there was confusion and lack of documentation regarding dietary orders, with discrepancies between physician orders for a full liquid diet and the facility’s implementation of a clear liquid diet. The resident reported receiving only minimal nutrition, such as broth and a protein supplement, and expressed that her concerns were not being addressed. The facility’s policies for monitoring significant weight changes and ensuring dietitian involvement for high-risk residents were not followed, resulting in the failure to provide adequate nutrition and prevent further weight loss.