Failure to Timely Implement Dietitian Recommendations and Notify Provider of Ongoing Weight Loss
Penalty
Summary
Facility staff failed to follow the dietitian's recommendations in a timely manner and did not notify the resident's physician or nurse practitioner of ongoing weight loss. The resident, who had a diagnosis of dysphagia, experienced significant weight loss over several months. The dietitian initially recommended a nutritional supplement (Med Pass 2.0) twice daily after noting weight loss, and later increased the recommendation to three times daily, also suggesting consideration of an appetite stimulant. However, there was a delay of 20 days before the appetite stimulant was ordered, and no further interventions were implemented despite continued weight loss. Throughout this period, the resident's weight continued to decline, with documentation showing a total loss of 35 pounds over approximately one year. Despite monthly assessments by the dietitian, there was no evidence that the resident's physician or nurse practitioner was notified of the ongoing weight loss after the initial intervention. Interviews confirmed that the nurse practitioner was unaware of the continued weight loss and that facility staff did not timely communicate these changes or implement recommended interventions.