Failure to Prevent Severe Weight Loss Due to Incomplete Nutrition Monitoring and Care Plan Implementation
Penalty
Summary
A deficiency occurred when the facility failed to prevent a resident from experiencing unplanned severe weight loss by not implementing multiple aspects of the resident's care plan and not following the registered dietician's (RD) recommendations. The resident, who had a history of hemiplegia, hemiparesis, protein-calorie malnutrition, and dysphagia, was identified as malnourished and at risk for further nutritional decline. The care plan required staff to monitor and document meal intake percentages for each meal and to offer nutritional supplements if intake was below 50%. However, meal intake was not consistently recorded, and there was no documentation that supplements were provided when intake was low. The RD had recommended providing large-portion meals for the resident on two separate occasions, but these recommendations were not reflected in the physician's orders, nor was there evidence that the recommendations were communicated to or implemented by the physician. Additionally, after significant weight loss was identified, there was no documentation that an interdisciplinary team (IDT) meeting was conducted to address the resident's actual weight loss or to update the care plan accordingly. The facility's policy required notification of the physician and dietician for significant weight changes and updating the care plan, but these steps were not documented as completed. As a result of these failures, the resident experienced severe weight loss over a short period, ultimately requiring transfer to an acute care hospital for further intervention, including the placement of a feeding tube. Interviews with facility staff confirmed that meal intake was not consistently documented, supplements were not always offered as required, and RD recommendations were not followed through with physician orders. The Director of Nursing acknowledged that the facility's policies and procedures for managing resident weights and nutritional care were not followed in this case.