Failure to Address Significant Weight Loss
Penalty
Summary
The facility failed to identify and address significant weight loss in a timely manner for Resident R121, as evidenced by a review of facility policies, clinical records, and staff interviews. The resident, who was admitted with diagnoses including cerebral infarction, rheumatoid arthritis, and protein-calorie malnutrition, experienced a 17.5% weight loss within one month. Despite this significant weight loss, the clinical nutrition/dietary note dated 1/9/25 did not document the resident's weight history, failing to identify and assess the resident's significant weight loss. Furthermore, the nutritional care plan initiated on 1/30/25 did not identify the significant weight loss as a nutritional problem and lacked updated goals and interventions to monitor, reassess, and address the resident's specific nutritional concerns. During an interview, the Registered Dietitian confirmed that the facility did not document or address the significant weight loss in the clinical notes or care plan, leading to the deficiency in maintaining the resident's nutritional status.
Plan Of Correction
Resident # 121 no longer resides at the facility. All residents with significant weight loss have the potential to be affected. The Registered Dietician will be educated on the facility policy for weight assessment and intervention by DON/Designee. The DON/Designee will audit weights obtained in the last 30 days to ensure all residents with significant weight loss are assessed by the Registered Dietician and ensure that the care plans are updated for residents with significant weight loss. The DON/Designee will audit weights weekly x 4 weeks to ensure residents with a significant weight loss are assessed by the Registered Dietician and care plans are updated. Results of the audits will be forwarded to the center QAPI committee for review and recommendations.