Failure to Monitor Significant Weight Changes
Penalty
Summary
The facility failed to adequately monitor weight changes for two residents, leading to deficiencies in maintaining acceptable nutritional and hydration status. Resident 34, who has diagnoses including dysphagia, diabetes mellitus, and dementia, experienced a significant weight loss of 7.44% between August and October 2024. The facility did not record a weight for September 2024, did not reweigh the resident after the October weight was obtained, and failed to notify the dietitian of the weight loss. This lack of action was confirmed by the Nursing Home Administrator and Director of Nursing. Resident 79 experienced a significant weight gain of 6.90% over a 19-day period. The dietitian noted that the previous weight was likely inaccurate and that the resident continued to receive outside food and snacks despite counseling. However, the facility did not reweigh Resident 79 to confirm the significant weight change. The Director of Nursing confirmed that the weight was not re-checked after the significant change was identified.
Plan Of Correction
1. Facility cannot retroactively monitor weight loss and weight gain for resident 34 and resident 79. 2. Facility performed a house wide audit to ensure no other resident trigger for weight loss or weight gain. None found. 3. DON, or designee, will educate nursing staff on weight policy, to include reweights and notifications to dietician. 4. DON, or designee, will perform random audits to ensure weights/reweights are being obtained as ordered and notification to dietician, weekly for 2 weeks, then monthly for 2 months. Results of audits will be submitted to monthly QAPI for review and recommendations.