Delay in Physician Notification of RD Recommendations Following Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a resident received timely and appropriate services to maintain optimal nutritional status. Specifically, the resident experienced a weight loss of 6 pounds (4.3%) over six days, as documented in the medical record. The registered dietitian (RD) conducted a nutrition assessment and recommended daily multivitamin with minerals, snacks three times daily, and Glucerna shakes with meals due to inadequate oral intake. These recommendations were documented on 9/9/25. However, the RD's recommendations were not communicated to the physician until nine days later, resulting in a delay in obtaining the necessary physician orders for the interventions. Facility policy required timely monitoring and intervention for undesirable weight changes, but the charge nurses did not relay the RD recommendations to the physician as required. This delay was acknowledged by both the LVN and the DON during interviews, confirming that the resident did not receive the recommended nutritional interventions in a timely manner.