Failure to Address Significant Weight Loss
Penalty
Summary
A resident with severe cognitive impairment, aphasia, dysphagia, and dementia experienced significant, unaddressed weight loss over a period of several weeks. The resident's medical record showed an 8% weight loss in one week and an 11.5% loss over 90 days, but there was no evidence that this significant weight loss was addressed for over three weeks. The resident was not on a physician-prescribed weight loss prevention regimen, and the care plan indicated a goal to prevent significant weight loss, which was not met. Interviews and record reviews revealed that the facility's process for monitoring and responding to weight loss was inadequate. The Registered Dietician (RD) was not notified promptly of the resident's weight loss, and the Certified Dietary Manager (CDM) did not bring the resident's case to the Standards of Care meetings. The facility relied on periodic percentage-based reviews rather than timely responses to actual weight changes, resulting in a lack of intervention despite ongoing weight loss. The facility's policy required multidisciplinary assessment and intervention, but this was not followed in the resident's case.