Failure to Prevent and Address Weight Loss and Dehydration
Penalty
Summary
The facility failed to provide a comprehensive, resident-centered plan of care to prevent, identify, and treat weight loss and dehydration, resulting in actual harm to a resident with severe cognitive impairment and multiple comorbidities. This resident, who was at nutritional risk and required staff assistance with activities of daily living, experienced significant unaddressed weight loss and dehydration. Despite documented weight loss from 98 pounds on admission to 91 pounds over several weeks, there was no evidence of timely or effective interventions, such as ensuring the administration and documentation of ordered nutritional supplements, or the implementation of additional care plan interventions. The care plan did not address hydration needs or the resident's physical ability to consume food and fluids, nor did it reflect the need for staff assistance with eating and drinking in light of the resident's cognitive status and poor appetite. Meal intake records showed inconsistent and often minimal food and fluid consumption, with several days of no intake documented and no evidence that alternative food options or supplements were offered or accepted. There was also a lack of documentation regarding the reasons for poor intake or any attempts to address it. The resident's declining intake and condition were not communicated to the medical provider or registered dietitian, and weights were not consistently obtained as ordered. When the resident's condition deteriorated, staff failed to recognize or report the change in a timely manner, resulting in the resident being found in a severely debilitated state and subsequently hospitalized for severe dehydration and malnutrition. A second resident experienced significant weight loss without timely dietitian follow-up or implementation of recommended interventions. Despite documented weight loss exceeding 5% in one month, reweights were not completed as requested, and recommended nutritional supplements were not initiated promptly. Staff failed to document attempts to encourage intake or offer alternative supplements when intake was low. Facility policy required prompt reweighting, notification, and intervention for significant weight changes, but these steps were not consistently followed, contributing to the deficiencies identified.