Failure to Notify Dietician and Reassess Tube Feeding After Change to NPO Status
Penalty
Summary
A deficiency occurred when the facility failed to ensure that services were provided in accordance with professional standards for a resident with a gastrostomy tube (g-tube). The resident, who had diagnoses including type 2 diabetes mellitus, dementia, and failure to thrive, was admitted with orders for both enteral feeding and a puree diet. Over time, the resident became NPO (nothing by mouth) following a speech language pathologist's evaluation, and meal trays were discontinued. Despite this significant change in nutritional status and a documented weight loss, the registered dietician (RD) was not notified or involved in reassessing the resident's nutritional needs after the change to NPO status. The medical record review showed that the RD had only completed an initial assessment upon admission and had not evaluated the resident after the transition to NPO or in response to the observed weight loss. The RD stated she was unaware of the resident's change to NPO status and the associated weight loss, and indicated she would have wanted to be informed to assess for any necessary changes in the tube feeding regimen. The DON confirmed that the RD should have been made aware of the change and evaluated the resident accordingly. Documentation of the resident's meal intake percentages was requested but not provided. Observations and interviews confirmed that the resident was frail, dependent on staff for all care, and received all nutrition and hydration via the g-tube. The failure to notify the RD and to provide timely reassessment after a significant change in nutritional status and intake constituted a lapse in following professional standards of care for residents with feeding tubes.