Failure to Notify Resident Representative of Change in Condition and Dietary Orders
Penalty
Summary
The facility failed to notify a resident's representative of significant changes in the resident's condition, specifically regarding weight loss and new dietary interventions. The resident, who had severe cognitive impairment and multiple complex diagnoses including acute respiratory failure, chronic ulcer, dysphagia, and severe protein calorie malnutrition, experienced a notable weight loss during their stay. Despite physician orders for weekly and then monthly weights, the resident's admission weight was not documented, and there were gaps in weight documentation leading up to discharge. The resident's weight dropped from 159 pounds at hospital admission to 145 pounds within two weeks, and the dietician was notified of this loss, recommending additional nutritional supplements and changes to the resident's diet. Physician orders were updated to include nutritional supplements and a change in diet consistency, but there was no documentation that the resident's representative was informed of the weight loss, the recommended interventions, or the new physician orders. Staff interviews and policy review confirmed that the facility's policy required notification of the resident's representative in the event of changes in condition or treatment, but this did not occur. This deficiency was identified during a complaint investigation and affected one resident out of those reviewed for changes in condition.