Failure to Address Significant Weight Loss and Provide Ordered Nutritional Supplements
Penalty
Summary
The deficiency involves the facility’s failure to adequately address and monitor significant weight loss for two residents, including failure to provide ordered nutritional supplements and to complete required weekly weights. One resident with severe cognitive impairment and multiple diagnoses, including dysphagia, CHF, acute kidney failure, and anxiety disorder, experienced a documented 15.7% weight loss in 30 days and 10% in 90 days. The care plan identified risk for altered nutrition and ordered house supplements, snacks, and diet per physician orders. A dietitian recommended adding frozen nutritional treats twice daily and weekly weights after the significant weight loss was identified. Although an order for frozen nutritional treats with lunch and dinner was entered, the dietary department was not notified, and the meal ticket was never updated to include the supplement. On observation, the resident’s lunch tray did not include the frozen nutritional treat, and the CNA confirmed the meal ticket did not list it. Despite this, the MAR showed 100% consumption of the frozen nutritional treat, and the RN acknowledged documenting 100% intake without verifying that the supplement had been served or consumed. The Dietary Director confirmed that frozen nutritional treats had not been sent for the resident during the month and that half portions were being provided at the resident’s request, which the dietitian was not aware of. The dietitian stated she relied on medical record documentation to determine if supplements were being consumed and confirmed that inaccurate documentation could affect additional interventions. The DON verified that weekly weights ordered for the resident were not completed as recommended, and that the resident should have been weighed on specific weekly dates but was not. For the second resident, who had severe cognitive impairment, dementia with behavioral and mood disturbances, anorexia, and other comorbidities, the facility failed to follow its own policy for weight monitoring and notification after significant weight losses. The resident’s care plan and orders included weekly weights, Boost supplementation, total assistance with meals, offering alternatives if less than 50% of a meal was consumed, and notifying the nurse manager if meals or supplements were refused. Despite this, documented weights showed a 10.7% loss over six days and a 5.71% loss over three days, with no documentation that the dietitian or physician was notified. Subsequent dietary notes recorded weight warnings and acknowledged fluctuations and loss but did not show follow-up interventions or timely notifications after these significant losses. The dietitian later reported she was not notified of the significant weight loss episodes and instead identified one of the losses herself and requested a re-weigh order days later. She stated that staff were supposed to notify her of any weight change of 5 pounds or more, which did not occur during the July/August or November losses. Review of the facility’s Weight Monitoring and Nutritional Intervention policy showed that any weight change of 5% or more required a re-weigh the next day and notification of the dietitian, but this policy was not followed for this resident. Across both residents, the survey findings document failures to provide ordered nutritional supplements, failures in communication between nursing and dietary, inaccurate intake documentation, and failures to complete required weight monitoring and notifications in accordance with facility policy.
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