Failure to Monitor Nutritional Status and Notify Physician
Penalty
Summary
The facility failed to ensure proper monitoring of nutritional status and did not notify the physician of significant weight changes for two residents. Resident 38, who had diagnoses including moderate protein-calorie malnutrition, dementia, and congestive heart failure, experienced a significant weight loss of 20.8 pounds over a period of three weeks. Despite the facility's policy requiring re-weighs and physician notification for significant weight changes, Resident 38 was not re-weighed until a week later, and the physician was not notified of the weight loss until December 10, 2024, several weeks after the initial weight loss was recorded. The dietitian's note on November 26, 2024, acknowledged the weight loss but did not document any communication with the physician. Resident 79, who had diagnoses including hypertension, hyperlipidemia, and osteoporosis, did not have a weekly weight measure recorded for the week of September 15 through 21, 2024, as required by physician orders and facility policy. Interviews with the Nursing Home Administrator and Director of Nursing confirmed the absence of the weight measure and acknowledged the expectation for weekly weights to be obtained. These deficiencies highlight lapses in the facility's adherence to its own policies regarding weight monitoring and physician notification, potentially impacting the residents' health management.
Plan Of Correction
1. R 38's provider was notified of weight loss identified from 11/3-11/26/24 on 12/10/24. R 79 no longer resides in the facility. 2. Residents with orders for weekly weights will be audited that weights were completed as orders, reweighs obtained as necessary, and follow-up with physician and dietitian notification has occurred as appropriate. The facility has reviewed and revised its current procedure for weights for obtaining weights/reweights and to include notification of the physician and dietitian as appropriate. 3. The facility will re-educate Nursing Staff and the Dietician on the revised weight procedure to include weekly weights, reweights, and to include physician and dietitian notification of identified weight changes. A weekly weight committee has been established to include a review of weekly and monthly weights to validate reweighs and notification to physician and dietitian has occurred. 4. The Director of Nursing or designee will perform audits of at least 5 residents/week and documented weights to validate weight procedure has been followed to include re-weighs and proper notifications as necessary. Results of audits will be forwarded to the facility Quality Assurance and Performance Improvement Committee x 12 weeks for review and recommendation.