Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident, identified as Resident R67, who experienced significant weight loss. The facility's policy required communication between nursing staff and the dietician to prevent, monitor, and intervene in cases of undesirable weight loss. However, despite the resident's weight loss of 20.29% over a short period, there was no documented evidence that the facility obtained weekly weights as ordered by the physician. The dietician, Employee E5, acknowledged awareness of the weight loss but attributed it to a scale malfunction without testing the scale or implementing protocols for addressing the weight loss. Additionally, the medical doctor, Employee E20, was aware of the resident's significant weight loss but did not address it in his documentation or provide new orders related to the weight loss. The resident's care plan included goals to maintain adequate nutritional status and interventions to monitor and report signs of nutritional issues, but these were not effectively implemented. The lack of timely and appropriate interventions contributed to the deficiency in maintaining the resident's nutritional status.
Plan Of Correction
Step 1 Resident R67 weight obtained. Step 2 All residents requiring weekly weights related to weight loss audited to ensure weights obtained according to physician orders. Step 3 Nursing staff educated on ensuring weekly weights are obtained as ordered by the physician. Step 4 Managers/designee will conduct audits weekly x4, monthly x2 to per facility protocol. Findings will be reviewed during QAPI meeting.