Failure to Notify Family of Significant Weight Loss and Dietary Changes
Penalty
Summary
The facility failed to notify the family or emergency contact of a resident who experienced significant weight loss and changes in nutritional management. Clinical record review and staff interviews revealed that a resident with severe cognitive impairment, multiple diagnoses including anemia, diabetes mellitus, traumatic brain injury, malnutrition, and respiratory failure, experienced notable weight loss over several months. The resident was dependent on staff for eating and received the majority of their nutrition via a feeding tube. Progress notes documented an 8.8-pound (5%) weight loss in one week and an 11.9-pound (7.3%) weight loss in one month, with a total loss of 21.4 pounds (12.4%) over three months. The dietician made recommendations to adjust tube feeding to address the weight loss. Despite these significant changes, there was no documentation in the clinical record that the resident's family or emergency contact was notified about the weight loss or the dietary recommendations. The DON confirmed that she could not locate any documentation of family notification and acknowledged that, although she had multiple conversations with the family, these were not documented. Facility policy required prompt notification of the resident's representative in the event of significant changes in the resident's condition, but this was not followed in this case.