Failure to Address Severe Weight Loss and Nutritional Risk
Penalty
Summary
The facility failed to assess and address the nutritional status of a resident who experienced a severe weight loss of 7.07% within a one-week period. The resident, who had multiple diagnoses including metabolic encephalopathy, neurogenic bladder, BPH, diabetes, and a urinary tract infection, was moderately cognitively impaired and required assistance with eating. Despite a significant weight loss being documented, there was no evidence that the registered dietitian (RD) or facility staff implemented or documented any interventions to address the weight loss or prevent further decline. Facility policies required regular monitoring of weights, prompt notification of significant changes, and individualized nutritional interventions. The resident's weight dropped from 230.5 lbs to 214.2 lbs in one week, and subsequent laboratory results showed low total protein and albumin levels, indicating poor nutritional status. There was no documentation of RD follow-up or progress notes after the initial evaluation, and no evidence of reweighing or new interventions following the significant weight loss. Interviews with staff confirmed that the expected process for addressing significant weight changes was not followed, and the RD was not notified or did not document any follow-up actions. Staff interviews revealed that while CNAs reported poor intake to nurses and offered snacks, and nurses were aware of the need to monitor and report weight changes, the required escalation to the RD and implementation of further interventions did not occur. The DON and other staff confirmed that there was no RD documentation after the weight loss was identified, and the process for monitoring and addressing nutritional risk was not followed as outlined in facility policy. This failure resulted in actual harm to the resident.