Failure to Monitor and Address Significant Weight Loss in Residents
Penalty
Summary
The facility failed to implement a systematic approach to monitor and address significant weight loss in two residents, resulting in deficiencies related to nutrition and hydration status. For one resident with diagnoses including enterocolitis due to clostridium difficile, anemia, and gastro-esophageal reflux disease, there was a severe weight loss of 51 lbs. (23.29%) over six months, 14 lbs. (6.39%) in one month, and 30 lbs. (14%) in another period. Despite physician orders for nutritional supplements, snacks, and weekly weights, the resident was not assessed and monitored by the interdisciplinary team (IDT) in a timely manner. The care plan identified the risk for weight loss, but interventions such as IDT assistance during meals and monitoring were not effectively implemented. Additionally, a Change of Condition (COC) was not initiated when severe weight loss occurred, and there was no documentation of physician or legal representative notification at those times. Another resident with a diagnosis of dysphagia experienced a significant weight loss of 17 lbs. (12.14%) in one month. The care plan included interventions such as multivitamin/mineral supplements, a protein supplement beverage, and weekly weights for three weeks. However, the resident's weights were not monitored as ordered, with a 14-day gap between recorded weights. The resident reported being informed of weight loss but was unaware of the extent and stated there was no discussion about the facility's response to the weight loss. The care plan did not reflect updated goals or interventions regarding the risk for weight loss, and the required monitoring was not completed as ordered by the physician. Interviews with facility staff, including the Registered Dietitian (RD) and Director of Nursing (DON), confirmed that the process for addressing significant weight changes was not followed. The RD acknowledged that the physician was not notified of the severe weight loss, and the DON verified that a COC, including physician and legal representative notification, RD consult, and IDT evaluation, should have been initiated immediately upon identification of significant weight loss. The administrator and DON were made aware of these findings.