Failure to Implement Dietitian Recommendations and Follow Up on Weight Loss Evaluation
Penalty
Summary
Facility staff failed to implement the dietitian’s recommendations and to follow up on a physician-ordered GI consult for residents experiencing weight loss. One resident with dementia, adult failure to thrive, mild protein-calorie malnutrition, and other comorbidities continued to lose weight despite supplementation and meal assistance. The dietitian assessed this resident and documented that a GI telehealth consult had been ordered due to ongoing weight loss and a history of being underweight. However, there were no GI consult notes in the electronic or paper medical record, and the Acting DON confirmed that staff did not have the results of the consult, leaving the facility unable to determine if there were any recommendations related to the resident’s weight loss. The dietitian also ordered weekly weights times four for this same resident, but the weight for one of the scheduled weeks was not obtained, as confirmed by the Regional Director of Clinical Operations. A second resident, admitted with a diagnosis including malnutrition, was assessed by the dietitian for weight loss, and the dietitian again recommended weekly weights times four. Staff obtained only two weights and then stopped, and the dietitian did not see this resident again after the initial assessment. These missed weights and lack of follow-up on the GI consult occurred for two of three residents reviewed for weight loss during a complaint survey.
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