Failure to Conduct Physician Assessment for Unplanned Weight Loss
Penalty
Summary
The facility failed to ensure that a physician assessment was completed for a resident experiencing unplanned weight loss. The facility's policy required residents to be weighed on admission, weekly for the first four weeks, and monthly thereafter. However, the weight data for the resident showed a significant weight loss of 11.4 pounds over seven days, and there was no evidence that the resident was weighed as ordered on December 30, 2024. Additionally, the clinical record lacked documentation that the physician was notified of the weight loss or that an assessment was conducted in response. The resident was identified as being at nutritional risk due to a pressure ulcer and other dietary needs. Despite this, the facility did not follow its policy to monitor the resident's weight effectively. The registered dietician confirmed that the resident was not assessed in a timely manner and that there was no documented evidence of physician notification or assessment. This oversight in monitoring and assessing the resident's nutritional status contributed to the deficiency noted in the report.
Plan Of Correction
This plan of correction is submitted to comply with federal regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. R65 The facility cannot go back retroactively to correct this issue. The DON/designee conducted an audit of residents with significant weight loss in the last 30 days to ensure the residents' physician was made aware of the weight loss and that documentation was completed by the physician in response to the weight loss. The DON/designee educated the residents' physician that when a weight loss occurs, the physician is expected to complete an assessment of the resident and document it on the clinical record. The DON/designee will audit residents with significant weight loss to ensure physician notification of the weight loss and that documentation was completed by the physician in response to the weight loss. Audits will be done weekly x 4 weeks then monthly thereafter. Results of these audits will be submitted to the quality assurance committee to determine if further action is needed.