Failure to Prevent Significant Weight Loss Due to Inadequate Nutrition Monitoring
Penalty
Summary
Facility staff failed to ensure adequate nutrition and prevent significant weight loss for one resident, who experienced a 39-pound weight loss over approximately nine months. The resident, who had multiple complex medical diagnoses including septic shock, chronic kidney disease, and chronic wounds, was cognitively intact and required extensive assistance with activities of daily living. Despite being at high risk for malnutrition and having a care plan in place that included weekly weights, supplements, and monitoring of meal intake, staff did not consistently implement these interventions. The resident repeatedly refused to be weighed, but staff only attempted to obtain a weight once per month and did not document any further efforts or alternative strategies to monitor weight as ordered. There was no documentation of weekly weights after the dietitian updated the order, and staff continued to record outdated weights from several months prior. Additionally, there was no evidence that staff closely monitored the resident's food and nutrient intake, or that they assessed or addressed the resident's ongoing complaints about the quality and palatability of facility-provided food. The resident reported a decreased appetite, altered taste, and dissatisfaction with the food, stating that he often had to order outside food when possible due to the poor quality and high salt content of facility meals. Despite these complaints and the resident's significant weight loss, there was no documentation of updated food preferences or efforts to address his concerns. Staff interviews confirmed awareness of the resident's complaints and the importance of nutrition for wound healing, but there was no evidence of effective interventions to prevent further decline.