Failure to Recognize and Respond to Significant Resident Weight Loss
Penalty
Summary
Facility staff failed to recognize and respond to significant weight loss in a resident admitted for comprehensive rehabilitation with multiple diagnoses, including cerebral infarction, hypertension, type 2 diabetes with hyperglycemia, and a sacral wound. Upon admission, the resident's weight was documented as 128 lbs, a notable decrease from the ideal body weight of 154 lbs. Despite a dietician's recommendation for weekly weights and monitoring due to malnutrition risk, weekly weights were not performed after admission. The next recorded weight, taken three weeks later, showed a further drop to 102.2 lbs, representing a 20% loss. There was no evidence that the physician, dietician, or family were notified of this significant weight loss as required by facility policy. Additionally, the dietician did not assess the resident until 11 days after the documented weight loss, and the resident was not discussed in weekly risk meetings until 13 days after the weight loss was identified. The facility's policy required immediate notification of the dietician in writing for significant weight changes, but this was not followed. Interviews with the physician confirmed the expectation for prompt notification in such cases, which did not occur.