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.
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 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.
Delayed Re-Weight and Weight Loss Recognition A resident with dementia, a pelvis fracture, and severe cognitive impairment had ordered weight monitoring, but staff did not obtain or document a timely re-weight after repeated refusals and a questionable low weight. An LPN struck out one weight, forgot to enter another re-weight, and did not document the significant weight loss or related notifications. The APRN and RN were not aware of the weight loss until the record was reviewed, and staff relied on aides to report poor intake.
Failure to address significant weight loss: A resident with dysphagia, dementia, MS, and feeding difficulties had repeated significant weight loss while on a regular, whole texture, thin liquid diet. The care plan identified the resident as at risk for weight loss, but the record showed no added MD orders or other nutrition interventions, and the RD acknowledged awareness of the loss but did not follow up.
A resident with multiple risk factors for malnutrition did not have weekly weights obtained or documented as ordered, and after a significant weight loss was recorded, a re-weight was not performed promptly to confirm accuracy. Staff interviews revealed confusion about responsibilities and lack of a clear policy for re-weighing after significant changes, while the MAR allowed weights to be signed off without actual documentation.
A resident admitted after a hospital stay with elevated kidney function labs did not have hydration needs properly assessed or documented. Required intake and output (I&O) monitoring was incomplete, estimated fluid needs were not consistently recorded, and no hydration or nutritional assessment was completed after admission or following a syncopal episode. Staff interviews confirmed that facility policy for hydration assessment and documentation was not followed.
A resident did not receive sufficient food and fluids to maintain their health, as required. The facility failed to ensure the necessary provision of nutrition and hydration.
A resident with multiple health issues, including malnutrition and chronic wounds, experienced rapid and significant weight loss. Despite facility policy requiring prompt notification and care plan revision for significant weight changes, there was a delay in dietician evaluation due to missed notifications and prioritization issues. The facility lacked a specific policy on the timing of dietician assessments for significant weight loss.
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