Failure to Monitor Significant Weight Loss in a Resident
Penalty
Summary
The facility failed to monitor a resident who experienced a significant weight loss of 6.71% in one month. According to the facility's policies and procedures, a weight loss of 5% or more in one month is considered a significant change of condition, requiring assessment and monitoring. The resident, who had severe cognitive impairment, was noted by the registered dietitian to have lost weight likely due to a recent acute care hospitalization, and dietary interventions were recommended, including increased milk intake and weekly monitoring of weights, oral intake, laboratory tests, and skin condition. Despite these recommendations and the facility's own protocols, there was no documented evidence that the resident was assessed or monitored for the significant weight loss. Observations showed the resident consumed only 20% of a lunch meal on one occasion, though intake was higher at breakfast on another day. Interviews with staff confirmed that the required monitoring and assessment following the change in condition did not occur. Facility leadership acknowledged that the resident was not monitored as required after the significant weight loss.