Failure to Address Significant Weight Loss in Resident with Complex Medical Needs
Penalty
Summary
A significant deficiency occurred when the facility failed to address a 19% weight loss in one month for a resident with multiple complex medical conditions, including Parkinson's disease, dementia, diabetes, dysphagia, and several advanced pressure ulcers. The resident was admitted and re-admitted to the facility, and her care plan identified her as being at nutritional risk due to wound infection, dysphagia, and increased nutritional needs for wound healing. Despite these risks and a documented significant weight loss, the care plan was only revised to note the weight loss, without adding new or revised interventions to address the issue. The resident's weight dropped from 154.1 lbs to 124 lbs over a one-month period, as confirmed by multiple re-weighs. The care plan approaches included monitoring for signs of malnutrition and significant weight loss, providing supplements, and ensuring total assistance with feeding. However, when the significant weight loss was identified, neither the physician nor the registered dietician implemented new interventions. The registered dietician acknowledged the weight loss and stated that no additional measures were put in place, citing limited options and the absence of a fortified foods program. The director of nursing was unaware of the weight loss and stated that she would have expected new interventions to be implemented. Throughout this period, the resident continued to receive the same supplements and assistance with feeding, and her oral intake was documented as adequate. Despite this, the significant weight loss was not addressed with additional interventions, and the facility's policy requiring action in response to significant weight changes was not followed. The deficiency was identified through interviews, record reviews, and policy review, which confirmed that the facility failed to take appropriate action to maintain the resident's nutritional status.