Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to provide timely assessments and implement interventions to maintain acceptable nutritional parameters for two residents. Resident 112 experienced a significant weight loss of 24.5 pounds over a period from November 2024 to January 2025, with no weight obtained in December 2024 and no reweight conducted after the significant weight loss was noted in January 2025. Despite the resident's diet being upgraded, there was no further monitoring or intervention for her weight loss until February 2025, when a dietitian noted the resident's significant weight loss and risk for malnutrition, yet no new interventions were initiated. The resident's weight continued to fluctuate without appropriate reweights or interventions. Resident 88 also experienced a severe weight loss of 14 pounds in March 2025, which was not assessed in a timely manner. The facility lacked a system to notify the dietitian of significant weight changes, resulting in a delay in addressing the resident's nutritional needs. The dietitian only completed a weight change note four weeks after the severe weight loss was identified. These deficiencies highlight the facility's failure to adhere to its policy for monitoring and addressing significant weight changes, leading to inadequate nutritional care for the residents.