Failure to Prevent and Address Significant Unplanned Weight Loss
Penalty
Summary
The facility failed to identify, assess, and implement effective interventions to prevent unplanned significant weight loss in three residents. For one resident with Alzheimer's disease, vascular dementia, heart failure, and dysphagia, there were repeated nursing notes documenting poor appetite, refusal to eat, and minimal intake over several weeks. Despite these ongoing issues, there was inconsistent notification to the physician, lack of timely dietary follow-up, and no new interventions added for months. The resident experienced a 14% weight loss over six months, with documentation showing variable and often poor intake, and no evidence of completed calorie counts as ordered. The dietitian was not notified of significant weight loss in March, and interventions remained unchanged despite continued decline. Another resident with Alzheimer's disease, vascular dementia, and heart failure experienced an 8% weight loss in one month. There was no documentation that the physician was notified of the weight loss in March, and dietary notes were missing for February and March. Although a calorie count was ordered, there was no evidence it was completed or reviewed. The dietitian confirmed not being notified of the weight loss and did not follow up on the calorie count. Interventions in the care plan were not updated in response to the ongoing weight loss, and the resident's intake remained variable and often poor. A third resident with malignant neuroendocrine tumors, gastrostomy, and dysphagia experienced a 10% weight loss in one month. The resident was hospitalized and returned with a G-tube, but there was no documentation of new interventions to address the weight loss prior to hospitalization. The dietitian was not notified of the weight loss before the resident left for the hospital, and the care plan lacked updated interventions for nutritional risk. Weights were inconsistently documented, and the facility's process for monitoring and responding to significant weight loss was not followed as outlined in their policies.