Failure to Monitor and Assess Resident's Weight Loss
Penalty
Summary
The facility failed to adequately monitor and assess weight loss for a resident diagnosed with osteoporosis and dementia. The facility's policy required that any weight change of five pounds or more be retaken for confirmation, and if verified, the dietitian should be notified. The resident experienced a weight loss from 127 lbs. to 117 lbs. between March 1 and April 5, which was confirmed with a reweighing on April 7, showing a weight of 120 lbs. Despite this verified weight loss of 7 lbs. (5.5 percent), there was no evidence that the dietitian was notified or assessed the resident's nutritional status until April 30, during a regularly scheduled quarterly assessment. The Administrator confirmed the lack of notification to the dietitian, which was a deviation from the facility's policy.
Plan Of Correction
Resident 5 weights to be reviewed for accuracy. Resident 5 assessment to be completed by dietician. All resident weights and assessments to be reviewed for accuracy and timeliness for all current residents with a lookback review. Resident weights to be reviewed to ensure follow up completed according to the facility policy. A random monthly audit of weights to be completed by nursing administration or designee monthly. Education provided to licensed nursing staff and dietician regarding the weight policy. Findings from the audits will be reported to QAPI for 3 months.