Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to monitor and address significant weight loss in one resident, as evidenced by a lack of timely follow-up on the recommendations made by the Registered Dietitian (RD). The resident experienced a weight loss of 11 lbs, or 11.1%, over three months, which met the facility's criteria for significant weight change. Despite the RD recommending nutritional interventions, including the provision of a high-calorie nutritional formula and additional supplements, there was no documentation that these recommendations were communicated to the physician or addressed by the Interdisciplinary Team (IDT) Nutrition. The resident's weight status was not monitored as required, and the facility's policy for early identification and assessment of weight changes was not followed. Interviews with the Assistant Director of Nursing (ADON) and the Food & Nutrition Services Director confirmed that the resident's weight loss was not properly tracked or managed. The ADON was unable to provide evidence that the RD's recommendations were implemented or that the resident's ongoing weight loss was monitored. The Food & Nutrition Services Director also stated that the resident's weight should have been monitored weekly, indicating a lapse in adherence to facility protocols for nutritional monitoring and intervention.