Failure to Timely Address Significant Weight Loss and Nutritional Needs
Penalty
Summary
Facility staff failed to ensure that a resident with a history of significant weight loss maintained acceptable nutritional status. Upon admission, the resident had already experienced a 40-pound weight loss due to self-imposed starvation and was placed on a full liquid diet per hospital discharge instructions. Despite this, the resident lost an additional 18 pounds in the first nine days at the facility and a total of 24 pounds over five weeks. Observations revealed that the resident's meal trays were repetitive and sometimes missing prescribed items, such as ice cream, which the resident expressed a preference for and was ordered to receive. The facility did not implement timely interventions to address the resident's ongoing weight loss. There was a delay in initiating nutritional supplements, with the first supplement order not placed until nearly a month after admission. The registered dietician's initial malnutrition screening inaccurately assessed the resident as low risk and did not account for the significant weight loss. There was also a lack of documented follow-up or reassessment by the dietician until several weeks later, during which time the resident continued to lose weight and developed wounds. Additionally, the facility failed to promptly arrange a necessary gastroenterology appointment to address the resident's underlying condition of achalasia, which restricted dietary advancement. Staff interviews revealed confusion and lack of communication regarding the scheduling of this appointment, with no evidence of attempts to secure an earlier consultation until several weeks after admission. The facility's own policies required timely weight monitoring, interdisciplinary review, and provider notification for significant weight changes, but these procedures were not followed, resulting in the resident's continued decline.