Failure to Identify and Address Significant Weight Loss and Poor Intake
Penalty
Summary
The deficiency involves the facility’s failure to accurately assess and respond to a resident’s significant weight loss and declining nutritional status. The facility had policies requiring monitoring of weight and nutritional status, identification of recent or rapid weight loss, and notification of the physician, dietitian, and family of significant changes, including possible fluid and electrolyte imbalances. Despite these policies, the resident’s weights from admission to discharge showed a total loss of 14.1 pounds (8%) over 22 days, with early rapid losses documented, but no evidence that this weight loss was identified as significant or that appropriate assessments were completed. During the resident’s stay, meal intake records showed that out of 61 meals served, six had no documented intake percentage, and of the 55 documented meals, 29 reflected less than 50% consumption and 15 reflected less than 25% consumption. A speech therapist observed a sharp decline in the resident’s abilities, including talking less and not feeding herself, and reported this to an LPN, who documented that the therapist had to assist the resident with eating and that the resident seemed to be declining. However, the LPN later stated they did not recall notifying the physician or family of the resident’s decline or weight loss. The registered dietitian confirmed not being informed of the weight loss and did not see the resident in the facility, instead making diet recommendations based only on prior speech therapy notes. Laboratory results showed a downward trend in the resident’s potassium levels while at the facility, from 3.5 mEq/L on one date to 2.6 mEq/L on the day of discharge, compared to a prior hospital potassium level of 4.0 mmol/L. The nurse practitioner and primary care physician both confirmed they were not notified of the resident’s weight loss or poor intake, and both acknowledged that limited meal consumption could lead to weight loss and electrolyte imbalance. The resident’s family also reported not being informed of the weight loss or lack of food consumption. The resident was ultimately sent to the hospital for altered mental status and possible stroke, and the hospitalist documented that the resident was admitted with hypokalemia secondary to severe malnutrition and dehydration, stating that the lack of food and drink at the facility was the cause of the hypokalemia.
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