Failure to Monitor and Address Resident Weight Loss and Nutrition Orders
Penalty
Summary
The facility failed to ensure that services provided met professional standards for a resident with significant nutritional needs. A resident with dementia, dependent on staff for eating and other activities of daily living, experienced ongoing weight loss. The resident was on a mechanical soft diet and had orders for monthly weights and a daily nutritional supplement (magic cup). However, the resident's weights for August and September were not entered into the clinical record, and there was no documentation that the medical provider or family were notified of the weight loss. The dietitian's recommendation to increase the supplement to twice daily was not implemented, and the resident continued to receive the supplement only once daily with supper. Interviews and record reviews revealed that the registered dietitian had not evaluated the resident since July, and the dietary manager was unaware of current residents with weight loss. The process for monitoring and reporting weight changes was not followed, as weights were not consistently recorded or communicated to the appropriate staff. The lack of documentation and communication led to missed interventions, including the failure to increase nutritional supplementation and notify the medical provider of significant weight loss, as required by facility policy.