Failure to Communicate and Implement Dietitian Recommendations for Resident with Weight Loss
Penalty
Summary
A resident with a diagnosis of mild protein-calorie malnutrition experienced significant weight loss, dropping from 126 lbs to 119 lbs over a ten-day period. The registered dietitian (RD) made recommendations to liberalize the resident's diet by discontinuing the no added salt restriction and to increase the frequency of a nutritional supplement (Boost) from twice to three times daily. These recommendations were documented in the resident's nutrition notes but were not communicated to the physician for approval, nor were they implemented. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that the facility's policy and procedure on Assessment and Management of Resident Weights was not followed. The policy required licensed nurses to notify the physician of the RD's recommendations and to document the physician's response, including any refusal and rationale. The DON acknowledged that there was no documentation showing the RD's recommendations were carried out or communicated as required.