Failure to Identify and Address Significant Weight Loss
Penalty
Summary
The facility failed to identify and address a significant weight loss in a timely manner for a resident with multiple medical conditions, including Type 2 Diabetes, End Stage Renal Disease, Anemia, and dependence on dialysis. The facility's policy required prompt re-weighing, notification of the dietitian, and intervention when significant weight loss was detected. Despite these protocols, the resident experienced a 7.5% severe weight loss over a six-week period, which was not addressed by the clinical dietitian or reflected in the nutrition progress notes. The resident's care plan indicated a need to maintain weight within a specific range and to receive dietary evaluation and changes as needed, but these actions were not taken when the weight loss occurred. Observations and interviews revealed that the resident was eating 75-80% of meals and was cognitively intact, able to express preferences and concerns about food choices. The resident reported a decreased appetite and a willingness to consume nutritional supplements, but there was no evidence that additional supplements or interventions were provided after the significant weight loss was identified. The facility's documentation showed inconsistencies in weight monitoring practices, with weights being taken by both facility staff and the dialysis team, sometimes using uncalibrated or malfunctioning scales. This led to discrepancies in recorded weights and confusion about the resident's actual nutritional status. Further compounding the issue, communication between staff members regarding significant weight changes was inconsistent. The dietary technician and CNAs described different processes for weight monitoring and reporting, and the clinical dietitian was not notified or did not respond to the severe weight loss in a timely manner. The facility administrator acknowledged issues with scale accuracy and had recently arranged for calibration, but this action occurred after the deficiency was identified. As a result, the resident continued to lose weight, dropping to 80% of ideal body weight, without appropriate assessment or intervention from the clinical team.