Failure to Identify and Address Significant Weight Loss
Penalty
Summary
The facility failed to provide adequate nutritional care and services for a resident with multiple diagnoses, including dementia, diabetes mellitus, and dysphagia. The resident experienced a significant and unaddressed weight loss, dropping from 179 pounds to 131.7 pounds within a short period, representing a 26.55% decrease. Despite this substantial weight loss, there was no documentation of physician notification, referral to the dietitian, or a nutritional assessment by the dietitian. The care plan identified the resident as being at risk for altered nutritional status, but no updated interventions or reviews were documented in response to the weight loss. The clinical record lacked evidence that the resident was re-weighed after the initial significant weight loss was identified, despite repeated notes from the mental health nurse practitioner highlighting the issue and requesting re-weighs. There was also no documentation of review by the Interdisciplinary Team (IDT) regarding the weight loss. The resident herself reported noticeable weight loss and ill-fitting clothes, yet no action was documented to address her nutritional needs or investigate the cause of the weight loss. Interviews with facility staff, including the DON and MDS Coordinator, confirmed that the weight loss was not properly identified or coded, and that the dietitian did not follow up as required. The facility's own policy required reporting significant weight changes to the physician and dietitian, as well as obtaining re-weights for discrepancies, but these steps were not taken for this resident. The deficiency was identified during a complaint investigation.