Failure to Timely Address Significant Weight Loss
Penalty
Summary
A resident with diagnoses including a right pubic fracture, major depressive disorder, anxiety disorder, and Alzheimer's disease experienced significant weight loss over several months. The resident was assessed as having severe cognitive impairment but was independent with eating. The care plan identified the resident as being at risk for altered nutrition and included interventions such as monitoring weights, encouraging intake, and providing supplements as ordered. Despite these interventions being listed, the facility failed to implement them in a timely manner after a documented significant weight loss. The resident's weight dropped by 8.6 pounds (an 8% loss) within 30 days, but no re-weight was completed as requested, and no new interventions were implemented for several months. Weights continued to decline, with no action taken from August through January, despite ongoing losses. Interventions such as nutritional supplements and increased monitoring were not ordered until several months after the initial significant weight loss. Staff interviews confirmed that the re-weight was not completed as requested and that interventions were delayed.