Failure to Address Insidious Weight Loss in a Resident
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident who experienced an unplanned, insidious weight loss over several months. The resident, who had multiple diagnoses including congestive heart failure, type 2 diabetes, hypothyroidism, Alzheimer's disease, and dementia, lost 10 pounds (6.8%) in three months and 16 pounds (9.8%) in six months. Despite this ongoing weight loss, the facility did not implement timely or adequate interventions to address the issue. The resident's dietary intake was inconsistently documented, and the registered dietitian (RD) repeatedly noted that the resident was meeting estimated nutritional needs based on meal intake percentages, without specifying time frames or providing evidence that caloric intake actually met the resident's requirements. The RD discontinued a nutritional supplement due to frequent refusals but did not recommend alternative interventions until significant weight loss had already occurred. The RD also did not participate in interdisciplinary team (IDT) meetings or communicate with the resident's representative regarding weight goals or preferences. The facility's documentation showed that weight variance IDT meetings were not held to address the resident's ongoing weight loss until after a significant decline was documented. Additionally, the resident's food preferences were not adequately assessed or accommodated, as the dietary manager did not consult with the resident's family and the facility did not offer culturally preferred foods, despite the resident's cognitive impairment and expressed dissatisfaction with the meals. Further, the facility failed to accurately document significant weight loss in the Minimum Data Set (MDS) assessments, and staff interviews confirmed that required reviews and discussions regarding the resident's nutritional status and weight changes were not consistently performed. The lack of timely intervention, inadequate assessment of intake and preferences, and insufficient interdisciplinary communication contributed to the resident's continued insidious weight loss.