Failure to Ensure Adequate Nutrition and Weight Maintenance
Penalty
Summary
A deficiency occurred when the facility failed to ensure adequate nutrition and weight maintenance for one resident with multiple medical diagnoses, including anxiety, osteoarthritis, depression, glaucoma, anemia, cataracts, macular degeneration, neuropathy, and a pacemaker. Over a six-month period, the resident experienced a weight loss of 12.77%, dropping from 141 lbs to 123 lbs. The resident was placed on weight monitoring and classified as Nutrition at Risk due to a wound, but this monitoring was discontinued in March after staff determined weights were stable, despite continued weight loss. The resident was prescribed a nutritional supplement (Boost) twice daily starting in late February, but still lost an additional 3.5 lbs after the supplement was initiated. Progress notes from the physician inaccurately stated there was no weight loss, and the Nutrition at Risk Quarterly Review recommended only continued monitoring without further interventions. Meal consumption records showed the resident ate less than 50% of meals for 35 out of 90 recorded meals in June. Interviews revealed that the nurse practitioner was unaware of the ongoing weight loss and expected to be alerted by the DON or the facility's computer system if a resident lost 10% of their weight in six months, which did not occur. The registered dietician noted the weight loss followed a pattern and was not alarmed, relying on the DON or ADON to communicate follow-up needs. Observations showed the resident was not provided with special utensils, visual aids, or redirection during meals, despite care plan interventions indicating the need for assistance and encouragement with eating, as well as monitoring for significant weight changes and offering meal substitutes when intake was low.