Failure to Monitor and Maintain Nutritional Status for Tube-Fed Resident
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident with complex medical needs, including gastrostomy status, muscle wasting, malnutrition, and other chronic conditions. The resident was dependent on enteral feeding and required close monitoring of weight and nutritional intake. Despite physician and dietitian orders for weekly weights and ongoing monitoring, the facility did not obtain or document weekly weights on multiple scheduled dates. This lapse in monitoring occurred even though the resident had a history of weight fluctuations and a care plan goal to maintain adequate nutritional status. The resident experienced significant weight loss over a short period, with documented weights showing a decrease from 87 lbs. to 82.2 lbs., and further to 78 lbs. within a few weeks. There were discrepancies in weight measurements due to inconsistent use of scales (wheelchair scale versus mechanical lift scale), and staff interviews revealed confusion about the most accurate method for weighing the resident. The assistant director of nursing acknowledged responsibility for ensuring weekly weights were performed but admitted to lapses in oversight, especially in the absence of a director of nursing. Interviews with staff, including CNAs, the ADON, the registered dietitian, and the nurse practitioner, confirmed that the resident's weight monitoring was inconsistent and that communication lapses occurred regarding weight changes and the need for intervention. The registered dietitian was not made aware of missed weekly weights or significant weight loss until after the fact. Facility policy required multidisciplinary assessment and regular monitoring of residents at risk for nutritional problems, but these procedures were not consistently followed for this resident.