Failure to Address and Communicate Significant Resident Weight Loss
Penalty
Summary
The facility failed to ensure that adequate nutritional care and services were provided to a resident with a history of diabetes mellitus and muscle wasting. The resident experienced significant weight loss over a short period, losing 4 pounds in one week and an additional 5 pounds in the following weeks. Although the Registered Dietitian (RD) had previously recommended a fortified diet and the physician had agreed to the change, there was no documentation or evidence that the resident's continued weight loss in May was addressed. The care plans included monitoring for weight loss and malnutrition, but there was no indication in the progress, dietary, or nutritional notes that the ongoing weight loss was discussed or acted upon after the initial intervention. Interviews with facility staff revealed a breakdown in communication and monitoring. The RD, Director of Nursing (DON), and Dietary Supervisor (DS) were not made aware of the resident's continued weight loss in May, despite facility policies requiring notification and intervention for significant changes in condition. The DON acknowledged that a change of condition should have been reported and that the nursing staff failed to communicate the weight loss to the appropriate team members. Facility policies emphasized the importance of multidisciplinary monitoring and timely intervention for undesirable weight loss, but these procedures were not followed in this case.