Failure to Prevent Significant Weight Loss Due to Inadequate Nutrition and Documentation
Penalty
Summary
The facility failed to prevent significant weight loss in two residents who were reviewed for weight loss. One resident, who had multiple complex medical conditions including chronic respiratory failure, protein-calorie malnutrition, cerebral palsy, and dependence on a ventilator, experienced a substantial weight loss of 31.1 pounds over four months. This resident was prescribed tube feedings to meet caloric and nutritional needs, but medication and feeding records showed that the resident did not consistently receive the prescribed volume of tube feeding solution on numerous occasions. The registered dietician confirmed that the resident did not receive the required caloric intake for extended periods, and the director of nursing was aware of the issue but could not provide any corrective action that had been taken at the time. Another resident, with a history of stroke, diabetes, heart failure, and dysphagia, lost 14.6 pounds, representing a 13% weight loss in 90 days. Review of this resident's food acceptance records revealed multiple instances where no food acceptance was documented for several meals over the preceding 30 days. The registered dietician could not verify whether the resident had received dietary trays for the meals with missing documentation. The director of nursing confirmed that there were multiple dates and mealtimes without documentation of food acceptance and could not explain the lack of documentation. Both cases demonstrate that the facility did not ensure residents consistently received adequate nutrition and hydration as ordered, either through tube feeding or oral intake. The lack of consistent documentation and follow-through on prescribed nutritional interventions contributed directly to significant weight loss in both residents.