Failure to Address Resident Weight Loss and Implement Nutritional Interventions
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable parameters of nutritional status, specifically regarding weight loss, as required by regulation. One resident experienced a 9.37% weight loss over eight months, with no documentation from the Dietitian addressing nutritional concerns or recommending interventions to address the weight loss. The resident's care plan included interventions such as determining food preferences, encouraging meal completion, monitoring weight, and regular Dietitian assessments, but these interventions were not fully implemented. The resident had a history of cerebrovascular disease, hypertension, and type 2 diabetes, and was on a regular diet with no supplements. Despite a documented poor appetite and a preference for certain foods, there was no evidence that the Dietitian assessed the resident or made recommendations during the period of weight loss. The resident's weight was recorded monthly, showing a steady decline, but the facility did not initiate additional interventions or document follow-up actions as outlined in their own policy for significant weight changes. Interviews revealed that the Dietitian only assessed residents with significant weight loss and did not document a conversation regarding a possible swallowing evaluation. The nursing staff noted the resident was eating less than 51% of meals, but no supplements were provided, and the resident's family expressed concern about the ongoing weight loss. The facility's policy required action for significant weight changes, but these steps were not taken or documented for this resident.