Failure to Notify Physician and Dietitian of Significant Weight Loss
Penalty
Summary
The facility failed to follow its own policies regarding the monitoring and management of significant weight loss for a resident. The resident, who had diagnoses including high blood pressure, diabetes, asthma, dehydration, severe protein-calorie malnutrition, and gastro-esophageal reflux disease, experienced an 11.5-pound weight loss over 56 days. Facility policy required that significant, insidious, or unintentional weight loss be reported to the Registered Dietitian (RD) and the physician, with subsequent assessment and intervention. However, there was no documentation that the RD or physician were notified of the resident's weight loss or of the hospital's recommendation for nutritional supplements upon the resident's return from hospitalization. The resident's care plan included monitoring for signs and symptoms of malnutrition and significant weight loss, with specific thresholds for reporting. Despite this, records showed gaps in meal consumption documentation and a lack of follow-up on the resident's nutritional status after multiple hospitalizations for conditions including hypoglycemia and diabetic ketoacidosis. The resident's weight continued to decline, and the resident reported concerns about weight loss and not having seen the RD for assistance. Interviews with staff, including the RD and physician, confirmed that they were not made aware of the resident's weight loss or the need for intervention. Facility staff interviews revealed that procedures for reviewing hospital records and implementing recommendations were not consistently followed. The RD stated that notification of significant weight loss was expected but did not occur. The physician also indicated that the facility should have identified the weight loss and involved the RD. The lack of communication and failure to implement required assessments and interventions directly contributed to the deficiency in providing adequate nutrition and monitoring for the resident.