Failure to Address Significant Weight Loss in Two Residents
Penalty
Summary
The facility failed to ensure that a physician supervised the care of two residents by not properly evaluating and addressing significant weight loss. For one resident with multiple psychiatric diagnoses, the medical record showed a 17.2 lb. (9.4%) weight loss over several months. The physician, during a progress note, referenced an outdated weight and did not review or address the recent weight loss. Nurse practitioners also saw the resident multiple times but did not mention or intervene regarding the weight loss, resulting in a lack of timely response to the resident's change in condition. For another resident with a history of cerebral infarction, depression, and repeated falls, the medical record indicated a 9 lb. (7.1%) weight loss in one month, with no documentation that the physician or dietician was notified. The physician's notes acknowledged the weight but did not address the loss, and a nurse practitioner noted poor intake and failure to thrive without initiating a nutritional consult. The Medical Director confirmed that the expectation was for providers to review and address pertinent information such as weight changes, which did not occur in these cases.