Failure to Assess and Intervene After Severe Weight Loss
Penalty
Summary
The facility failed to ensure that nutritional practices were implemented in accordance with professional standards of care for a resident who was at nutritional risk. The resident, who had a history of Parkinson's disease, dementia, and depression, experienced a severe and rapid weight loss that was not evaluated by the registered dietitian as required by facility policy. The policy specified that any significant weight change, such as a loss of 5% or more in one month, should prompt immediate notification to the dietitian and a reassessment of the resident's nutritional status. The resident's weight dropped from 166 pounds to 144 pounds within 19 days, representing a 13.25% loss of total body weight, which met the facility's criteria for severe weight loss. Despite this significant change, there was no documentation of a new nutritional assessment or updated dietary orders in the medical record following the weight loss. The only dietary interventions noted were supplements that had been ordered prior to the weight loss event, and no new interventions were implemented until several months later. Observations and interviews confirmed that the resident required assistance with eating and had a mechanically altered diet, but the severe weight loss was not addressed in a timely manner by the dietitian. Interviews with facility staff, including the unit manager, registered dietitian, and DON, revealed that while the resident was discussed in risk meetings and monitored for weight loss, the registered dietitian did not conduct a reassessment or document an evaluation after the severe weight loss occurred. The dietitian acknowledged that she should have performed a thorough review of the resident's nutritional status at that time, regardless of the resident's hospice status. The lack of timely assessment and intervention following the significant weight loss constituted a failure to provide adequate nutrition and hydration to maintain the resident's health.