Failure to Address Weight Loss and Implement Dietitian Recommendations
Penalty
Summary
The facility failed to address significant weight loss and did not follow dietitian recommendations for two residents reviewed for nutrition. For one resident, a notable weight loss of 12.2 lbs (7.17%) was documented over a period of just over a month, but there was no evidence of a follow-up nutrition evaluation or documentation regarding this change. Interviews with staff confirmed that the expected protocol—re-weighing, notifying the dietitian and provider, and documenting the change—was not followed, and the Director of Nursing validated that no documentation or intervention occurred after the weight loss was identified. For another resident with diagnoses of malnutrition and dysphagia, the dietitian recommended offering pudding and shakes twice daily to increase caloric intake. However, these recommendations were not implemented, as there were no physician orders for the suggested supplements after the assessment. The resident was admitted to hospice care and subsequently died in the facility. The Director of Nursing confirmed that staff did not follow the dietitian's recommendations for this resident.