Failure to Prevent Significant Weight Loss in Resident with Severe Malnutrition
Penalty
Summary
The facility failed to implement effective interventions to prevent significant weight loss in a resident diagnosed with type II diabetes, hypertension, anemia, severe protein-calorie malnutrition, and blindness. Despite being identified as at risk for weight loss and having a care plan that included interventions such as administering medications, providing dietary supplements, offering snacks, and monitoring intake, the resident experienced a significant weight loss of 6% in one month and 11.3% over six months. The resident's body mass index (BMI) remained below 14, indicating severe underweight status. Medical and dietary records showed that the resident's intake varied widely, with appetite described as mostly fair and intake ranging from 26% to 100%. Although the care plan called for interventions like nutritional supplements and high-calorie diets, there was no documentation of new or adjusted interventions in response to ongoing weight loss. Physician orders for appetite stimulants such as Megestrol Acetate were not consistently administered, as confirmed by the Director of Nursing and review of medication administration records. Interviews with facility staff, including the medical doctor, revealed a lack of awareness regarding the resident's weight concerns and the absence of a clear medical diagnosis contributing to the weight loss. Despite recommendations from dietary staff to add health shakes and ready care supplements, there was no evidence that these interventions were effectively implemented or that the resident's nutritional needs were consistently met, resulting in continued unintended weight loss.