Failure to Follow Up on Significant Weight Changes
Penalty
Summary
A deficiency occurred when the facility failed to follow up on significant weight changes for a resident with dysphagia and severe cognitive impairment. The resident, who required tube feeding due to difficulty swallowing, experienced notable fluctuations in weight over a short period, including both significant losses and gains. The care plan identified risks related to altered nutrition and hydration status but did not include specific interventions for nutrition. Weight records showed multiple instances of weight changes exceeding 5 pounds, which, according to the facility dietitian, should have triggered further evaluation. Despite these significant weight fluctuations, there was no documentation in the medical record indicating that the dietitian, physician, or nursing staff followed up on the changes. The dietitian stated she was not notified of the weight changes and would have expected to be informed to assess the resident. The lack of follow-up and absence of documentation regarding the significant weight changes constituted the deficiency identified by surveyors.