Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to ensure that the medical care of Resident #5 was adequately supervised by their Primary Physician, particularly in monitoring changes in the resident's medical status. Resident #5 experienced an 8.48% significant weight loss over a 90-day period, from October 2024 to January 2025, which was not addressed by their Primary Physician. The facility's policy required that significant weight changes be identified and referred to the attending Physician by the Clinical Dietitian for further review and interventions. However, the Clinical Dietitian did not identify the significant weight loss in a timely manner, and the Primary Physician did not document the resident's weight during their monthly review, leaving the weight change portion of the visit blank. Interviews revealed that the Clinical Dietitian focused primarily on month-to-month weight changes and did not have time to document significant weight loss notes for January 2025. The Charge Nurse was not informed of the significant weight loss, and thus did not notify the Primary Physician. The Primary Physician admitted to not realizing the omission in their documentation and stated they were not informed of the significant weight loss. The Medical Director emphasized that the Primary Physician should have documented the resident's weight and addressed any significant weight loss with appropriate interventions.
Plan Of Correction
Plan of Correction: Approved February 12, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A: Immediate Correction Action 1. Resident #5 who still resides at the facility was affected by this deficient practice. 2. Resident #5 was immediately placed on weekly weights. 3. Laboratory values ordered on [DATE] to identify any contributing factors. Values were in normal limits. 4. Physician #1 addressed weight loss in his monthly note. 5. Clinical Dietician #1 was counseled and re-educated to identify weight loss and follow facility Weight Monitoring Policy and Procedure. B: Identification of Others 1. All residents’ weights were reviewed and assessed for weight loss as outlined in the Weight Monitoring Policy and Procedure. No resident was identified as potential for this deficient practice. 2. The RN Educator re-educated the Physician, Dieticians, and Nursing staff to identify residents with weight loss as outlined in the Weight Monitoring Policy and Procedure. Upon identification of residents with weight loss, proper notification and documentation of weight loss is mandated. C: Systematic Review to prevent re-occurrence 1. The facility Weight Monitoring Policy and Procedure was reviewed by the Interdisciplinary Care Planning Team and no changes were made. 2. The DNS developed a Weight Monitoring Audit tool to identify residents with weight loss identified by this deficient practice to ensure communication and documentation. Ten residents will be audited weekly and thereafter ten residents will be audited quarterly for one year or until 100% compliance. D: Quality Assurance 1. The DNS/Designee will review the findings of the Weight Monitoring Audit. Negative findings will be immediately addressed by the DNS/Designee with onsite in-service and disciplinary action as needed. 2. The DNS/Designee will report the findings of this Weight Monitoring Audit quarterly at the QAPI meeting. 3. The DNS/Designee is responsible for ensuring the correction of this deficient practice.