A resident with dementia and multiple comorbidities experienced progressive weight loss that culminated in a documented 22 lb. drop within about one month, along with frequent poor meal intake. Despite care plan directives and facility policy requiring monitoring of weights, re‑weighing for significant changes, and notification of the RD and physician, staff did not obtain a confirming re‑weight, did not investigate the cause of the loss, and did not notify the RD or physician. Nursing notes did not address the resident’s poor oral intake, and no nutritional interventions were initiated. A family member’s repeated concerns about weight loss and a request for dietary supplements were not acted upon, and the RD reported not being informed of any weight‑related concerns prior to the resident’s hospitalization, where severe malnutrition and significant weight loss were formally identified.
Failure to monitor significant weight loss and provide ordered nutrition: Two residents with multiple medical conditions experienced continued weight loss because ordered weekly weights were missed, reweights were not obtained after losses of 5 lbs or more, and the physician/Dietitian were not timely notified. One resident also did not receive an ordered nutritional supplement until later, while the other was not served ordered pudding with lunch and ice cream with supper, and staff did not track intake or consistently prompt/assist with meals.
A resident with cognitive impairment and dependence for eating had a significant monthly weight loss, but the weight discrepancy was not reweighed in a timely manner and no interventions were documented after the initial loss was identified. The resident’s confirmed weight loss was later reviewed by the dietitian, who recommended supplements and monitoring, but the response occurred days after the loss was confirmed and weeks after the discrepancy was first noted.
A resident with severe weight loss and malnutrition and another resident with dementia and poor oral intake had physician-ordered weights that were not consistently obtained. The record also showed IV hydration was given, but the MAR and intake/output records did not document the fluid amounts or complete intake/output data as required. Staff and the DON/DNS could not explain the missing weights or incomplete documentation.
The facility failed to consistently obtain and document ordered and policy-required weights and meal intakes for three residents at risk for or experiencing significant weight loss and malnutrition. One resident with dementia and adult failure to thrive had long gaps without weights after admission and multiple readmissions, delayed post-readmission weights, and no timely re-weights after large weight changes, while meal intake was documented for only a small fraction of meals. Another resident with severe protein-calorie malnutrition, diabetes, and a stage 3 pressure ulcer had only three weights recorded over several months, with one month missing entirely and minimal meal intake documentation. A third resident with cancer, right heart failure, and HIV had a physician order for weekly weights that was not followed for multiple extended periods, including after readmission, and had incomplete meal percentage documentation. The RD and DON acknowledged expectations for timely admission/readmission weights, monthly and weekly weights per orders, re-weights after significant changes, and complete meal percentage recording, but weights, re-weights, and intake documentation were not consistently obtained or followed up.
A resident with a new stage 3 pressure ulcer did not receive a timely nutrition assessment after the wound was identified, despite a wound care note recommending optimized nutrition. Two other residents had significant weight changes that were not addressed in a timely manner: one had ongoing weight loss with limited dietary follow-up, and another had a large weight gain with a delayed reweight and delayed notification to the MD/APRN and family.
Failure to timely address significant weight loss. A resident with dementia, DM, CKD, and CHF had severe cognitive impairment, poor intake, and progressive weight loss despite ONS orders and nutrition monitoring. Surveyors observed the resident in bed at lunch refusing food and declining sandwiches, while meal tickets did not clearly direct regular provision of preferred sandwiches or finger foods. RD notes and physician orders showed ongoing supplementation, but the resident’s weight continued to decline and the record reflected delayed and incomplete nutrition interventions.
Failure to Reweigh After Weight Change: A resident with HTN, depression, and dysphagia had a documented weight gain followed by a later lower weight, but the facility did not reweigh the resident when the change occurred per its practice. Although the resident had MD orders for frequent weights, an RN stated the 2-lb gain may have been a mistake and could not explain why a reweigh was not done sooner.
Missed Quarterly Nutrition Assessment and Re-weight: A resident with DM2, GERD with esophagitis, Barrett’s esophagus, and other chronic conditions had monthly weights showing a >5 lb loss, but the dietician did not identify the loss for re-weighing and missed the required quarterly nutrition assessment tied to the resident’s MDS. Facility policy required re-weighing for a 5 lb variance and quarterly nutrition documentation to monitor dietary changes and whether interventions were working.
Failure to Monitor Intake and Output for Resident on Fluid Restriction: A resident with ESRD on hemolytic treatments and a 1000 mL fluid restriction had intake documented on the MAR that was consistently below the ordered limit, yet nursing notes did not show accurate I&O monitoring or physician notification when the restriction was not met. The resident also had documented weight gain and fluctuations, while an I&O binder at the nurses' station did not contain the resident's worksheet. The dietitian and DON were unable to confirm how staff were maintaining accurate fluid monitoring.
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