Failure to Notify Dietitian and Physician of Resident's Significant Weight Loss
Penalty
Summary
A deficiency was identified when a resident experienced significant weight loss, dropping from 154.6 to 144.0 pounds over approximately one month. The resident's last documented assessment by a dietitian occurred several months prior, and there was no evidence that the dietitian or physician was notified of the recent weight loss or the resident's low meal intake, despite care plan interventions requiring such notifications. Meal intake records showed frequent days with only one or two meals documented as eaten, and some days with no meals documented. Staff confirmed that there was no documentation of required notifications to the dietitian or physician regarding the resident's nutritional decline. The care plan for nutritional risk included interventions to monitor intake at all meals, offer alternate choices, and alert the dietitian and physician to any decline in intake, but these interventions were not followed as documented in the resident's records.