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Nutrition Is No Secret

August 1, 2003
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A liability lawsuit calamity caused by a nutritional "failure to communicate" BY LINDA WILLIAMS, RN
Nutrition Is No Secret

How one facility paid the ultimate price for not sharing its nutrition management ideas with a resident's family

BY LINDA WILLIAMS, RN Maintaining acceptable parameters of nutritional status among nursing home residents is a serious issue. Dr. Eric Tangalos, head of Geriatrics at the Mayo Clinic in Rochester, Minnesota, stated, "Sixty percent of all residents are susceptible to malnutrition because most have one or more conditions that interfere with eating." Statistics compiled by the government show that 25 to 30% of all nursing home residents are underweight, with 10 to 14% experiencing significant weight loss. At least 47% of nursing home residents need some assistance with eating, and of those, 21% are totally dependent. Dr. Tangalos further found that it is not unusual for one heavy-care resident to require a full 90 minutes to eat a 600-calorie meal. Given these facts, it's not surprising that lawsuits concerning resident weight-loss issues are on the rise. The following is a summary of a case against a nursing home concerning alleged improper nutritional care of a resident, resulting in a multimillion-dollar judgment.

The Situation
An elderly man with end-stage Alzheimer's was admitted to a nursing home. In the 29 months prior to his admission, he had been losing weight at an average of 0.6 pounds per month. As with many residents suffering with this terminal illness, the resident's appetite was poor, and he continued to lose weight at an average rate of 0.7 pounds per month. Nursing home staff members encouraged him to eat and provided appropriate supplements, but to no avail. The nursing staff requested that a feeding tube and IV be inserted to supplement the resident's oral diet, but the resident's wife refused as long as the resident was still capable of eating something.

As a result of inadequate nutrition, the resident began to develop decubitus ulcers. Some of them healed but others deteriorated. As the resident's condition worsened, his wife still refused the feeding tube and IV because he could still accept some nutrition orally. When he was transferred to a hospital for treatment of the decubitus ulcers, the hospital staff inserted an IV. But when his wife arrived at the hospital, she insisted that the nurse remove it. Shortly thereafter, the resident was transferred back to the facility, where he died within two weeks.

Two months later, the former resident's wife filed suit against the nursing home alleging that the facility failed to properly care for her husband by not providing adequate nutrition, which caused subsequent weight loss, contributing to the formation of decubitus ulcers.

The Trial
Through the discovery process, the nursing home's defense counsel questioned many of the facility's staff members, as well as an expert witness. Their statements showed that, given the progression of the Alzheimer's and lack of proper nutrition and hydration (because of the wife's refusal of the feeding tube and IV), the decubitus ulcers could not have been prevented or healed. During pretrial negotiations, however, the plaintiff would not drop the demand for $2 million, so the case went to trial.

During the trial, the deceased resident's spouse testified that she didn't think her husband needed the feeding tube or IV because "he was eating so well." When the resident's medical records were examined, the plaintiff's attorney showed the jury a food consumption sheet that stated the resident had been eating 100% of his meals, despite the witnesses' statements to the contrary and the fact that the resident weighed only 84 pounds at the time of his death. In addition, photographs of the emaciated resident were shown to the jury. After substantial deliberation, the jury awarded the plaintiff $580,000 in actual damages and $2.4 million in punitive damages. It was evident that the jury members had been upset by the lack of communication between the nursing home staff and spouse, as well as the misleading documentation in the resident's record.

Protective Measures
Unavoidable weight loss by a resident is a tragic situation that many nursing homes, like this one, have had to face because of the frailty and nature of many residents. As the case study demonstrates, a nursing home's response can lead to devastating consequences if the situation isn't handled properly and in the best interest of all parties involved. The following precautions are highly recommended:

1. Develop policies and procedures related to advance directives that address aggressive measures, such as feeding tubes. If the resident is capable of making his/her own decisions regarding end-of-life issues, it is important that his/her family understands them. The resident should sign an advanced directive that clearly states his/her wishes, and these actions should be documented in his/her chart for reference in future decision making.

2. Once a resident's physician has determined that a resident has a terminal prognosis and is expected to lose weight despite facility efforts, the resident's power of attorney (POA) designee for healthcare decisions must be contacted. If aggressive measures, such as parenteral or tube feedings, are an option, the POA must be given these choices. If these are refused, an advance directive should be initiated and signed by the responsible party and physician that clearly states the consequences of such action within the context of its risks and benefits.

The following recommendations apply more generally to nutritional management programs, and should at least prompt a facility to re-examine its policies: