Failure to Monitor and Address Significant Weight Loss and Poor Intake
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident maintained acceptable parameters of nutritional status. The resident, who had diagnoses including Alzheimer's disease and chronic obstructive pulmonary disease, experienced significant weight loss and poor oral intake over several months. Despite facility policies requiring monitoring of meal and snack intake, notification of clinical nutrition staff, and prompt assessment of significant weight changes, these procedures were not followed. The resident's meal and snack intake records showed frequent missed or refused meals and snacks, with many instances not documented or followed up as required. The resident's weight records indicated a substantial decline, with a 17-pound (10.6%) loss over six months and a 7.29% loss in one month. There was no documented evidence that the registered dietitian assessed the resident after the most recent significant weight loss, nor that the medical providers were notified of the ongoing decline. Staff interviews revealed a lack of communication and follow-through regarding the resident's poor intake and weight loss. Certified nurse aides and nursing staff were aware of the resident's meal refusals but did not consistently escalate the issue or ensure it was documented and communicated to the appropriate clinical staff. Further, the registered dietitian and medical providers were unaware of the resident's recent significant weight loss and poor intake, despite facility policy requiring notification and assessment in such cases. The registered dietitian acknowledged that high-risk lists and follow-up assessments were not maintained due to staffing shortages, and that only required quarterly assessments were being completed. As a result, the resident's nutritional decline was not addressed in a timely manner, and the required interdisciplinary interventions were not implemented.