Failure to Provide Adequate Assistance and Monitoring for Resident with Severe Weight Loss
Penalty
Summary
A resident with a recent history of stroke and a new diagnosis of Severe Protein Calorie Malnutrition experienced a significant weight loss of 7.65% in one month. Observations revealed that the resident was left asleep with an untouched breakfast tray, which was later discarded without any attempt to assist or encourage intake. During lunch, the resident was seen struggling to eat independently, with food falling off the fork and visible frustration, yet no staff assistance was provided. The care plan indicated the resident required extensive assistance with eating, but this intervention was not implemented during observed meals. Record review showed the resident was to be weighed weekly, but a required weight was missing from documentation. Despite the physician's note identifying significant weight loss and recommending a Registered Dietitian consult and nutritional supplements, there was no evidence of dietary follow-up or intervention in the progress notes. Staff interviews confirmed the resident had not been included in weight loss monitoring until after the deficiency was identified, and dietary interventions were not updated in a timely manner.