Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to address a significant weight loss in a resident diagnosed with dementia and dysphagia. According to the facility's policy, residents' weights are to be monitored weekly, and any weight change of three pounds or more should be reweighed within 24 hours to verify accuracy. Additionally, weight losses of 5% or more are to be reported to the physician and documented, with a care plan developed to address the concern. In this case, the resident experienced an 8.8-pound (5.81%) weight loss over five days, but there was no evidence that a reweigh was performed within 24 hours, nor that the nurse or dietitian reviewed the weight loss. No interventions were implemented to prevent further weight loss, and the physician was not notified until several weeks later. Further review showed that the resident continued to lose weight, with a total loss of 7.34% from admission over a three-month period. Despite this ongoing decline, there was no documentation of interventions or care plan adjustments to address the continued weight loss. Interviews with the dietitian and DON confirmed that no actions were taken in response to the significant and ongoing weight loss. The facility did not follow its own policies for monitoring, documenting, and responding to significant weight changes.