Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
A deficiency occurred when the facility failed to address and monitor significant weight loss for one resident. The resident, who had multiple diagnoses including metabolic encephalopathy, Alzheimer's disease, dementia, hypothyroidism, hyperosmolality, hypernatremia, and dysphagia, was dependent on staff for feeding. Upon admission, the resident's usual body weight was around 125 lbs, and care plans were in place to monitor for malnutrition and significant weight changes, including weekly weight checks for the first month and notification of the physician if significant changes occurred. However, a weight entry was missing for the week following admission, and the resident experienced a 13.5% weight loss over a week and a half, dropping from 124 lbs to 107.2 lbs, which was not promptly identified or addressed. Further review revealed that the resident continued to lose weight, reaching 102.6 lbs, and was not included in the most recent weekly weight meeting. The facility's policies required weekly weight monitoring for new admissions and for residents with significant unplanned weight loss, but these procedures were not followed. The registered dietician confirmed the lack of timely monitoring and intervention, which resulted in continued weight loss for the resident.