Failure to Monitor Significant Weight Loss
Penalty
Summary
The facility failed to timely monitor the nutritional parameters of a resident who experienced a significant weight loss. According to the facility's Weight Assessment and Intervention Policy, residents should be monitored for undesirable weight changes, and any significant weight loss should be verified and reported to the dietitian immediately. In this case, a resident admitted with dementia and a foot fracture experienced a 7.8% weight loss within eight days, which was not promptly addressed. The dietitian's note, dated nine days after the weight loss, questioned the initial weight's validity and suggested the weight loss might be related to the resident's adjustment to the facility and recent hospitalization. Despite the policy requiring weekly weight monitoring after a significant weight change, there was no documented evidence of weekly weights being obtained following the initial weight loss. Additionally, the resident's physician and representative were not timely notified of the significant weight loss. The resident was discharged from the facility without further documented weight monitoring, indicating a lapse in adherence to the facility's policy and procedures for managing significant weight changes.
Plan Of Correction
Step 1: Resident CR1 was discharged from the facility on 12/16/25. Step 2: Current residents newly admitted/readmitted to the facility, since 12/01/2024 have been reviewed to ensure weekly weights have been obtained as ordered. Any resident evaluated as having a weight change has been reviewed by the Registered dietician for applicable follow-up and notification to the physician and resident representative. Step 3: The Registered dietician and Clinical Administrative team have been re-educated by the RDCO-Clinical nurse to the facility process for monitoring of resident weights and applicable follow-up for those residents identified as having a weight change. Step 4: The Registered Dietician/Designee will complete random audits weekly x 4 weeks then monthly x 2 months to ensure residents weights are being obtained as ordered and that applicable follow-up for weight changes is being completed. Audits will be reviewed by the QA Committee for further follow-up as needed.