Failure to Address Significant Weight Loss and Nutrition Needs
Penalty
Summary
The facility failed to identify and address significant weight loss in a resident with diabetes and kidney disease. The resident experienced a weight loss of over 14% in just over three months, with documented weights showing a loss of 16.8 pounds. Despite physician orders to weigh the resident weekly and notify the provider if certain weight loss thresholds were met, there was no documentation of reweighing or provider notification after the resident met these criteria. Additionally, the resident was ordered a nutritional supplement, but records showed inconsistent administration and documentation, with the resident often not receiving the full amount or refusing the supplement. There was no evidence of a nutrition or weight loss care plan in the resident's comprehensive care plan, despite significant and ongoing weight loss. Staff interviews confirmed the lack of a care plan, absence of provider notification, and failure to attempt alternative nutritional interventions when the resident refused the prescribed supplement. The interdisciplinary team did not discuss the resident's weight loss, and the required documentation and follow-up actions were not completed as per facility policy and physician orders.