Failure to Complete Nutritional Assessment and Intervene for Significant Weight Loss
Penalty
Summary
Facility staff failed to provide appropriate nutritional care and services for a resident identified as being at risk for altered nutrition status. Upon admission, the resident, who had diagnoses including Multiple Sclerosis, dysphagia, and Major Depressive Disorder, did not receive a required nutritional assessment by the dietician. The facility's policy mandates that a nutritional assessment be completed within a day or two of admission and that significant weight changes be documented and addressed. Despite the resident experiencing a significant and severe weight loss over several weeks, there was no evidence in the clinical record that a nutritional assessment was completed or that the dietician made any recommendations or interventions. The resident's weight records showed a 7.5% to 9.8% weight loss over a short period, which met the facility's criteria for severe weight loss. Although the care plan identified the resident as being at nutritional risk and included interventions such as monitoring meal intake and obtaining lab work, there was no documentation of follow-up or action taken in response to the weight loss. Interviews with facility staff revealed that the dietician was unaware of the resident's weight loss and had not reviewed the weight records, and the unit manager was not informed of the issue. The lack of communication and failure to follow established protocols led to the deficiency in providing adequate nutrition and monitoring for the resident.