Failure to Conduct Timely Assessment for Significant Weight Loss
Penalty
Summary
The facility failed to complete a significant change assessment within 14 days for a resident who experienced a notable weight loss. The resident, who was at risk for nutritional decline due to advanced age and other health conditions, showed a 10.53% weight loss. Despite this significant change, there were no documented assessments related to the change in status, and the care plan was not updated accordingly. Observations and interviews revealed that the resident was not eating much, with staff noting that the resident consumed less than 25% of meals. The resident was on a mechanically altered diet with supplements, but there was no evidence of a change in condition being submitted or the physician being notified of the significant weight loss. The Registered Dietician (RD) confirmed that the resident's assessment had not been updated and that the interdisciplinary team had not met to address the resident's significant weight loss. The facility's policy required immediate notification of significant changes in a resident's condition, but this was not followed. The Director of Nursing acknowledged that the physician should have been contacted, and the care plan updated. The failure to conduct a timely assessment and update the care plan represents a deficiency in the facility's compliance with regulatory requirements.
Plan Of Correction
Resident #162 was discharged from the facility. Facility residents with a significant loss are at risk of being affected by not having a significant change assessment. Residents with significant loss were reviewed by the interdisciplinary team to determine if a significant change was indicated. A significant change assessment will be completed if needed. The Director of Nursing/Designee will educate the Minimum Data Set Coordinators, Registered Dietitian, and Dietary Tech on the criteria for determining a significant change with loss and the need to complete a significant change assessment if the criteria is met. The Director of Nursing/Designee will complete 3 random weekly audits on residents with significant loss to determine if a significant change Minimum Data Set assessment was completed. Results of the audits will be tracked and trended and reported to the monthly Quality Assurance Performance Improvement meeting until sustained compliance achieved.