Failure to Monitor and Document Weight Loss in Residents
Penalty
Summary
The facility failed to ensure timely and consistent weight monitoring and complete and accurate documentation for two residents, resulting in undetected weight changes and the potential for nutritional status decline. One resident, who was admitted with diagnoses including weakness and dysphagia and was receiving enteral feeding via PEG tube, experienced a significant weight loss of 6.48% over a short period. Despite this, there was no documentation from the Registered Dietitian (RD) or Dietary Manager (DM) regarding the weight loss after it was initially identified, nor was there evidence that the physician was notified. The resident's care plan was not updated to reflect the weight loss, and there was no follow-up assessment or intervention documented by the RD after the admission nutrition evaluation. Another resident, recently admitted following two surgeries, also experienced significant weight loss. The weight records showed inconsistent monitoring, with a three-week lapse between weighings and a substantial drop in weight. Staff interviews revealed confusion about who was responsible for monitoring and addressing weight loss, and the Dietary Manager admitted to not being aware of the resident's weight loss or having spoken to the resident about it. The facility's policy required weekly weights for new admissions and for residents with significant weight changes, but this was not followed for this resident. The facility's own Weight Management Policy stipulated that residents at risk or with significant weight changes should be weighed weekly, and that the RD should assess and make recommendations to prevent or treat unintended weight loss. However, these procedures were not followed for either resident, as evidenced by the lack of timely weight monitoring, absence of documentation, and failure to update care plans or notify the physician as required.