Failure to Implement Dietician Recommendations for Residents with Significant Weight Loss
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for two residents who experienced significant weight loss. Policy review showed that the facility was required to monitor weight changes and implement, monitor, and modify interventions as needed. For both residents, the Registered Dietician identified significant weight loss and recommended the addition of house supplements twice daily. However, these recommendations were not communicated to or implemented by the appropriate clinical staff. The Nurse Practitioner confirmed she was not made aware of the recommendations, and the DON acknowledged that the process for reviewing and acting on dietary recommendations was not followed due to staff absence and lack of follow-up. Both residents involved had complex medical histories, including severe cognitive impairment, dementia, and conditions such as aphasia, Parkinson's Disease, and adult failure to thrive. Despite documented weight loss—nearly 10% for one resident and over 5% for the other—there was no evidence that the recommended nutritional interventions were ordered or provided. The failure to implement these interventions resulted in actual harm to the residents, as the facility did not ensure their nutritional needs were met according to policy and clinical assessment.