Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to ensure that Resident #5 maintained acceptable nutritional and hydration status, as evidenced by an 8.48% significant weight loss over 90 days, which was not addressed by the Clinical Dietitian. The facility's policy requires the Clinical Dietitian to review residents' weight status and refer any significant weight changes to the attending Physician for further review and interventions. However, the Clinical Dietitian did not identify or address the significant weight loss of Resident #5, who has Type 2 Diabetes Mellitus and Hypertension, and a BIMS score indicating moderately impaired cognitive skills. The Clinical Dietitian was responsible for entering residents' weights into the Electronic Medical Record (EMR) and generating a report of significant weight losses. Despite the policy, the Clinical Dietitian focused primarily on month-to-month weight changes rather than cumulative weight loss over three months. Consequently, the significant weight loss of Resident #5 was not addressed in a timely manner, as the Clinical Dietitian had not yet completed the necessary documentation for January 2025. Interviews with facility staff revealed that the Clinical Dietitian did not inform the nursing staff of Resident #5's significant weight loss, which would have prompted the nursing staff to notify the resident's Primary Physician. The Director of Nursing Services confirmed that Clinical Dietitians are responsible for reporting significant weight losses to the Interdisciplinary Team and ensuring that the Primary Physician is informed to obtain new orders to address the weight loss. This oversight resulted in a failure to implement timely interventions for Resident #5's nutritional needs.
Plan Of Correction
Plan of Correction: Approved February 12, 2025 A: Immediate Correction Action 1. Resident #5 who still resides at the facility was affected by this deficient practice. 2. The clinical dietician for resident #5 reviewed the chart, initiated weekly weights, and added supplements. 3. Clinical Dietician #1 was educated on the facility policy on weight loss and weight monitoring on 1/24/25. B: Identification of Others 1. All residents that reside in the facility have the potential to be affected by this deficient practice. 2. The Chief Clinical Dietician ran the weight loss report for the month of (MONTH) on all residents to see if there were any residents with unidentified significant weight loss. There were no negative findings. C: Systematic Review to prevent re-occurrence 1. The facilities policy titled Weight Loss dated 2/2019 was reviewed by the Administrator, Medical Director and DNS and no changes were made to the policy. 2. The facilities policy titled Weight Monitoring was reviewed by the Administrator, Medical Director and DNS and no changes were made to the body of the policy, an effective date of 1/25/25 was given. 3. The RN Nurse Educator will re-educate all Clinical Dieticians on Weight Loss and Weight Monitoring policies and procedures. D: Quality Assurance 1. The DNS devised an audit tool to ensure that all residents experiencing weight loss are captured and documented according to the facilities policy and procedure. 2. The DNS and or designee will audit the weights of 10 residents weekly x 3 months and thereafter monthly for 1 year or until 100% compliance is achieved. 3. Any negative audit findings will immediately be addressed by the DNS/ designee with an onsite teaching/in-service, and disciplinary action as needed. 4. The DNS will report the findings of this audit quarterly at the QAPI meeting. 5. The DNS/ designee is responsible for ensuring the correction of this deficient practice.