Failure to Address Significant Weight Loss and Malnutrition
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident with end stage renal disease and dysphagia, resulting in significant weight loss. The resident, who was also a dialysis patient, experienced a 6.25% weight loss in one month, dropping from 155.1 lbs to 144.7 lbs. Despite facility policy requiring notification and intervention for significant weight changes, there was no evidence that a reweigh was performed or that the provider was notified after the weight loss was identified. The resident had a history of hospitalizations for falls, fractures, and failure to thrive, and had a physician's order for a mechanical soft diet with nectar thick liquids. Progress notes indicated ongoing refusal of meals, and concerns about declining health and dietary intake were communicated by the dialysis center. Staff interviews revealed that the facility had not had a Registered Dietitian since March, relying instead on a corporate dietician as needed. The dialysis center's RD and team attempted to contact the facility for three weeks regarding the resident's weight loss, but reported poor communication and lack of updates on the resident's condition. The Nurse Practitioner was unaware of the resident's weight loss until contacted by the dialysis center, and stated that she would have expected immediate notification. The Assistant Director of Nursing acknowledged that no reweigh was obtained and could not provide evidence of provider notification.