Failure to Monitor and Address Resident Weight Loss
Penalty
Summary
The facility failed to ensure that a resident's weight was obtained and documented as per facility policy for a resident receiving tube feedings. Resident 1, who was dependent on staff for all care and had a traumatic brain injury, was not weighed in January, March, May, or June 2024, despite the facility's policy requiring monthly weight checks. This oversight was confirmed by the Director of Nursing, indicating a lapse in monitoring the resident's nutritional health over time. Additionally, the facility did not address significant weight loss in another resident, Resident 62, who was cognitively intact and had Parkinson's disease. The resident experienced a drastic weight loss of 117.9 pounds over four months, with weights recorded from August to October 2024 showing a significant drop. Despite dietary notes questioning the accuracy of the weights and indicating a 7.6 percent weight loss in 30 days, there was no documented evidence of interventions to prevent further weight loss or notification to the physician. The Director of Nursing confirmed the lack of action regarding the resident's weight loss.
Plan Of Correction
1. The facility cannot retroactively address the findings. 2. Weights completed. Those with significant changes to have completion of nutrition assessment with MD and responsible party notification. 3. Director of Nursing or Designee to educate nursing staff including agency regarding weights and implementation of follow through documentation and notification. 4. Director of Nursing or Designee to complete weekly weight audits to ensure follow through of significant weight changes as well as the completion of interventions or re-evaluation of weights. Audits to be completed weekly for 4 weeks then monthly for 2 months. Results of this audit will be reviewed by the Quality Assurance and Improvement Committee for additional recommendations if necessary.