Failure to Implement Timely Interventions for Significant Weight Loss in Enteral-Fed Resident
Penalty
Summary
The facility failed to implement timely and appropriate interventions to address ongoing and significant weight loss in a resident who was dependent on enteral nutrition via PEG tube. The resident, who had a complex medical history including nontraumatic subarachnoid hemorrhage, conversion disorder, dysphagia, cerebral edema, and ventilator dependence, experienced a weight loss of 3.85% within the first month of admission, which progressed to a significant loss of 8.85% by the second month. Despite these documented losses, there was no evidence in the medical record of any interventions or responses from the facility until over two months after admission, when the weight loss had reached 11.15%. The resident's care plan and physician orders directed monthly weights and specified enteral feeding regimens, but there was no documented adjustment to the feeding orders or increased monitoring in response to the early weight loss. The resident's electronic medical record lacked evidence of dietary assessments or progress notes addressing the weight loss between admission and the point when the loss became significant. Staff interviews revealed that weights were typically obtained monthly, and that the dietitian was responsible for monitoring and making dietary adjustments. However, both the dietitian and administrative staff acknowledged that interventions, such as increasing the frequency of weight monitoring and adjusting feeding methods, should have been implemented sooner when the initial weight loss was observed. The dietitian also noted that no dietary assessments were completed in July when the first weight loss was documented, and that the resident remained on monthly weights despite ongoing decline. Facility policy required staff to report significant weight changes and for the dietitian to monitor and recommend interventions for residents receiving enteral nutrition. Despite this, the resident's weight loss was not addressed in a timely manner, and there was a lack of documentation of any interventions or increased monitoring until the weight loss became severe. Staff interviews confirmed that the process for monitoring and responding to weight loss was not followed as required, contributing to the continued decline in the resident's nutritional status.