Failure to Assess and Investigate Significant Weight Gain
Penalty
Summary
A resident with multiple complex medical conditions, including chronic respiratory failure, end stage renal disease, and dysphagia, was identified as being at risk for nutritional decline according to their care plan. The care plan required observation and evaluation of weight and weight changes. The resident experienced a significant weight gain of 7.6% in less than 30 days, increasing from 169.1 lbs to 181.9 lbs. Despite this notable change, there was no documentation in the progress notes acknowledging, identifying, or assessing the weight gain during the period reviewed. Interviews revealed that the dietitian entered the resident's weight into the system but did not notice the significant change at the time, and confirmed that no assessment or documentation of the weight gain occurred. The DON stated that the dietitian was responsible for monitoring weekly weights, not the nursing staff. Facility policy required reweighs within 48 to 72 hours for significant weight changes, but this was not done. The resident was later sent to the hospital due to a change in condition, but there was no evidence that the significant weight gain was investigated or addressed prior to this event.