A resident with an intracranial hemorrhage, chronic respiratory failure, DM2, tracheostomy, and G-tube had no nutrition care plan and experienced significant weight loss while receiving enteral feeds. The resident lost 13.5 lbs in one week, with additional weight loss documented later, but there was no documentation that the provider was notified. Interviews showed the LPN, RD, and DON recognized significant weight loss as a change of condition and stated the MD should be notified.
Failure to Notify Physician and Dietitian of Significant Weight Gain: A resident with Alzheimer’s disease, severe cognitive impairment, and a care plan for nutritional monitoring had weekly weights showing gains of 8.5 lbs and 5.4 lbs. Although the physician order required notification for weight gain of more than 5 lbs in one week, the record did not show that the physician or dietitian was notified, and the DON could not provide documentation of notification.
A resident with dysphagia, depression, intracranial injury, and a legal guardian had repeated significant weight changes that were not consistently re-weighed, documented, or communicated as required. Staff used different scales for weights, progress notes were missing for weight gains, and provider notes calling for dietary consults were not transcribed into orders. Interviews confirmed nurses were expected to re-weigh for a 5 lb change and notify the provider, RD, and responsible party, but those notifications did not occur as required.
A resident with diagnoses including Parkinson’s Disease and hydronephrosis had significant weight gains documented, but the EMR did not show notification to the provider or RD, and no reweigh was documented to verify the accuracy of the weights. Staff interviews showed weights were taken on shower days and entered verbally, while the RD questioned the accuracy of the weights and had no documentation requesting a reweigh.
A resident with protein-calorie malnutrition and dysphagia had an 8% weight loss in a month, but the facility did not document the ordered weekly weights. The resident was cognitively intact, denied refusing weights, and the DON said the charting order was not set up correctly, leaving no place to record weights after the last documented weight. The NP said the resident should have been re-weighed if a weight error was suspected and confirmed weekly weights were expected.
A resident with heart failure, chronic respiratory failure, and mobility issues was admitted with intact cognition and staff assist for meals, but the nutritional assessment and care plan did not address missing upper teeth and multiple lower teeth or the resident’s chewing difficulty. The resident told the surveyor that facility food was hard to chew without dentures, and staff interviews showed the issue was not incorporated into diet planning. The resident also had an MD order for weekly weights, but the record showed only admission and later weights, not the ordered weekly monitoring.
Failure to Obtain Admission Weight and Follow Ordered Weight Monitoring: A resident with DM2, dementia, anxiety, depression, muscle weakness, cognitive communication deficit, and COPD was admitted with an order for an admission weight and weekly weights, but the facility did not obtain a facility admission weight and only documented one later weight. The RD reviewed hospital discharge paperwork showing a higher weight, requested a re-weight, and noted an approximately 20 lb. loss when the resident was finally weighed. Staff could not show that the resident refused weighing, and the care plan was not revised after the weight discrepancy was identified.
A resident with multiple chronic conditions, including CHF, COPD, anemia, and low BMI, experienced a 9.94% weight loss in three weeks. The care plan called for weight monitoring, MD notification for significant weight changes, and supplements, but no new interventions were put in place when the loss triggered, and no documentation showed the MD was notified. The resident reported bland food and limited supplement options, while the RD, RN, and DON all acknowledged the loss was significant and should have been reported.
A resident with CHF, acute kidney failure, dysphagia, hemiplegia, and underweight BMI, receiving tube feeding, was admitted with orders for daily morning weights that were not consistently implemented, resulting in undocumented gaps and an 11-lb (9.55%) loss early in the stay, followed by further significant weight loss. The care plan identified high nutritional risk and later added daily weights after a 10% weight loss in 30 days, yet some ordered daily weights were still not documented and no refusals were recorded. The facility’s enteral nutrition policy required an RD assessment at admission for residents on tube feedings or consultation with an on-call RD before the first feeding, but the RD did not assess the resident until a week after significant weight loss was identified, and only one RD note was found. The DON acknowledged that daily weights were not started on admission despite the physician’s order and that the RD became involved only after weight loss, contrary to facility policy.
A resident with mild protein-calorie malnutrition and moderately impaired cognition experienced a documented drop in weight from 157.0 to 151.3 pounds over a short period. The NP entered a progress note indicating that the lower weight required a reweight for accuracy due to the significant decrease and expected the reweight to be completed within one day. The DON reported that NP recommendations, including reweights, are to be carried out within 24 hours and communicated to the unit nurse manager. However, surveyors found no evidence in the EHR that the resident was reweighed after the NP’s order, with the last recorded weight remaining at 151.3 pounds.
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