Failure to Notify RD and Physician of Significant Weight Loss
Penalty
Summary
The facility failed to assess and monitor the nutritional status of a resident who was at risk for malnutrition, resulting in a significant unplanned weight loss of 12% over 11 days. The resident had a history of surgical aftercare, dysphagia, and was on a mechanically altered diet, with documented difficulties in chewing and a preference for pureed foods. Despite being identified as at risk for malnutrition and having a care plan that required monitoring and notification of significant weight changes, there was no evidence that the Registered Dietitian (RD) or physician were notified of the resident's rapid weight loss. Family concerns about the resident's intake and weight loss were raised but not addressed by staff. Interviews with facility staff confirmed that the RD and physician should have been notified of the weight loss, as per facility policy, but this did not occur. The RD stated she relied on nursing management and the Certified Dietary Manager to monitor weights, but a change in staff may have led to the oversight. The Director of Nursing confirmed the lack of documentation regarding notification of the RD or physician. Review of physician notes also showed no acknowledgment or evaluation of the resident's significant weight loss during the relevant period.