Failure to Address Significant Weight Loss and Implement Nutritional Interventions
Penalty
Summary
The facility failed to ensure timely completion of weights, nutritional assessments, physician notifications regarding significant weight loss, and implementation of nutritional interventions for one resident. According to facility policy, any weight change greater or less than 5 pounds within 30 days requires a reweigh the next day, confirmation by a licensed nurse, and immediate written notification to the dietician and physician if the weight loss is verified. The resident was admitted with a weight of 110 lbs and diagnosed with left wrist and ankle fractures, hypertension, and unspecified protein-calorie malnutrition. Within 30 days, the resident experienced a 6% weight loss, dropping to 103.5 lbs. There was no documented evidence that a timely reweigh was performed, nor that the dietician or physician was notified of the significant weight loss. Further review of the resident's records showed that the nutritional assessment identified the resident as high risk for malnutrition and recommended two snacks daily as an intervention. The resident's care plan also included nutritional supplements and additional snacks. However, there was no documentation that the resident received the recommended two snacks twice a day. Interviews with the Regional Dietician and the DON confirmed the absence of documentation addressing the weight loss and the lack of evidence that the prescribed nutritional interventions were provided.