Failure to Address Significant Unplanned Weight Loss
Penalty
Summary
The facility failed to identify, comprehensively assess, and implement interventions for a significant weight loss in a resident who experienced a 9.7% decrease in body weight over one month. The resident, who had moderately impaired cognition, hemiplegia, depression, and required assistance with daily activities, was noted to have a weight drop from 236 pounds to 213 pounds within a month. Despite this significant change, there was no evidence that the weight loss was investigated or addressed by the care team, including the registered dietician, nursing staff, or the resident care coordinator. Documentation showed that the resident was at risk for nutritional alterations and had a care plan in place to monitor food and fluid intake, encourage eating, and provide assistance as needed. However, the significant weight loss was not identified or acted upon as required by facility policy, which mandates intervention for unplanned weight loss. Interviews with staff confirmed that the weight loss was not investigated to determine if it was an error or an actual loss, and no interventions were implemented in response to the change. The facility's policy requires that significant weight changes trigger a review and intervention by the registered dietician and notification of the physician. In this case, the registered dietician, nursing staff, and director of nursing all acknowledged that the weight loss was not addressed according to policy, and there was no documentation of any investigation or intervention for the resident's significant weight loss.