Failure to Monitor Weight and Implement Dietician Recommendations After Significant Weight Loss
Penalty
Summary
The facility failed to follow its own weight monitoring policy and did not implement a dietician's recommendation for a resident with significant weight loss. According to the facility's policy, residents with weight loss are to be weighed weekly, but records showed that after two separate episodes of significant weight loss, weekly weights were not consistently documented for the resident. The resident, who was severely cognitively impaired and had multiple diagnoses including dementia, depression, and anemia, experienced a 5.2% weight loss in less than a month and an 8.48% weight loss in one month. Staff interviews confirmed that weekly weights were not always performed after weight loss, and the Assistant Director of Nursing acknowledged that weekly weights were infrequent for both new admissions and residents with weight loss. Additionally, the dietician recommended a nutritional supplement to be given three times daily to address the resident's weight loss, but this recommendation was not communicated to the physician, and no corresponding physician's order was found in the medical record. The only supplement order present was for a different dosing schedule and duration. The dietician confirmed that the lack of a physician's order for the recommended supplement was due to an oversight. These failures resulted in the resident not receiving the recommended nutritional intervention and not being monitored according to policy after significant weight loss.