Failure to Address Significant Weight Loss in Tube-Fed Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and document interventions to address significant weight loss for one resident who was entirely dependent on enteral nutrition. The resident, admitted with diagnoses including intracerebral hemorrhage, encephalopathy, and dysphagia, was NPO and received all nutrition via tube feeding. Weight records show a decline from 165.0 lbs at admission to 142.5 lbs over several months, including multiple episodes of significant weight loss as defined by the facility’s own Nutrition Care Significant Weight Loss policy (e.g., 7.3% loss in 28 days and 4.84% loss in 7 days). Despite these documented losses, the resident’s comprehensive care plan did not include or address significant weight loss. Dietitian enteral nutrition assessments identified significant weight loss on multiple occasions but did not result in effective changes to the resident’s nutritional management. One assessment documented an 11.8% loss in one month, yet described the weight as stable and recommended continuing the current plan of care without additional interventions. A later assessment documented a 10.26% loss over three months and a total loss of 13.0% over five months, and recommended starting an Expedite enteral feeding formula for six weeks; however, this recommendation was not implemented due to lack of product availability. The dietitian stated that she does not complete care plans and did not address the absence of a weight loss care plan for the resident. Interviews with facility staff confirmed that the significant weight loss was not incorporated into the resident’s care plan and that required interdisciplinary collaboration and care plan updates did not occur as outlined in the facility’s nutrition policy. The DON acknowledged that weight loss should have been addressed in the plan of care but was not, and the MDS coordinator confirmed that newly identified problems such as significant weight loss are supposed to be care planned, yet no such care plan existed for this resident. The state guardian reported being informed by a hospital physician that the resident was not being fed properly at the facility, and facility lab results showed critically abnormal BUN, sodium, and chloride levels prior to the resident’s transfer to the hospital. These findings demonstrate that the facility did not ensure adequate nutritional interventions and care planning to prevent or address the resident’s significant weight loss.
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