Failure to Notify Physician and Dietician of Missed Enteral Nutrition and Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician and/or registered dietician when a resident did not receive physician-ordered enteral nutrition and failed to report significant weight loss for another resident. In the first instance, a resident with diagnoses including nontraumatic intracerebral hemorrhage, type II diabetes, and dysphagia was ordered nothing by mouth and was to receive Osmolite 1.5 via enteral feeding as their sole source of nutrition. On a specific date, the Osmolite was not available and was not administered, and there was no documentation that the physician or registered dietician was notified of the missed feeding. Interviews with the LNHA, RD, and DON confirmed that the enteral nutrition was not given and that appropriate notifications were not made, contrary to facility policy requiring immediate notification and documentation when there is a need to alter treatment significantly. In the second case, a resident with senile degeneration of the brain and vascular dementia, who was at risk for malnutrition, experienced a significant and rapid weight loss according to the medical record. The resident's weights showed a drop of 10 pounds in one day and 12 pounds in seven days, with no evidence that staff were made aware of the weight loss or that the registered dietician was notified. The DON confirmed that the EMR reflected this weight loss and that the last nutrition/dietary note was dated prior to the weight changes. The facility's policy required reweighs and notification of the dietician for significant weight changes, but there was no documentation that these steps were taken. Both deficiencies were identified through record review, interviews, and policy review, and involved failures to follow the facility's own policies regarding notification of changes in condition. The issues affected two of three residents reviewed for change in condition, and the facility census at the time was 54.