Failure to Identify and Address Significant Weight Loss in Tube-Fed Resident
Penalty
Summary
A resident with vascular dementia and severe cognitive impairment, who was dependent on a PEG feeding tube for nutrition and hydration, experienced a 6.03% weight loss over a 28-day period. The resident was noted to be minimally verbal, dependent for activities of daily living, and exhibited behaviors such as pulling on and disconnecting the feeding tube, as documented in multiple progress notes. The resident's Durable Power of Attorney (DPOA) was aware of the resident's agitation and attempts to pull on the tube but was not informed if the tube had ever been fully removed. There was no documentation in the medical record indicating that the feeding tube was pulled out or required replacement during this period. The facility's Registered Dietician (RD) and Director of Nursing (DON) acknowledged the significant weight loss and discussed it during a team meeting, with the RD suspecting a possible error in the weight measurement and requesting a re-weigh. However, the facility failed to identify and address the significant weight loss in accordance with their policies, which require monitoring, reassessment, and individualized care planning for significant unplanned weight changes. Additionally, there was no documentation of interventions or reassessment of the appropriateness and necessity of the feeding tube, as required by facility policy.