Failure to Provide Adequate Nutrition and Follow RD Recommendations
Penalty
Summary
A resident with dementia and severely impaired cognition experienced significant unintended weight loss of 11.48% over three months due to the facility's failure to provide adequate nutritional care and follow the Registered Dietician's (RD) recommendations. The resident was admitted with a weight of 135 pounds and was on a liberalized geriatric diet, with care plans indicating she made her own food choices and required staff to offer snacks and fluids throughout the day. Despite these interventions being documented, the resident's electronic medical record (EMR) showed a steady decline in weight, with no evidence of additional nutritional orders or consistent documentation of supplement intake. The RD noted limited meal intake, with most meals consumed at less than 26% and staff reporting the resident often preferred to sleep and declined food, stating she was not hungry. The RD recommended a trial of an appetite stimulant and nutritional shakes, but the clinical record lacked evidence that these recommendations were implemented or that the physician was notified of the significant weight loss. Staff interviews confirmed that while attempts were made to offer protein shakes, these were not documented, and there was uncertainty about whether RD recommendations were communicated to the provider or followed up with appropriate orders. Facility policy required staff to notify the physician of significant weight loss and document decisions for supplements, but the record showed these steps were not consistently taken. The resident's weight continued to decline, and staff and consultants acknowledged gaps in communication and documentation regarding nutritional interventions and physician notification. The failure to implement and document appropriate nutritional interventions and to follow RD recommendations contributed directly to the resident's ongoing weight loss.