Failure to Identify and Address Significant Weight Loss
Penalty
Summary
A significant deficiency occurred when the facility failed to identify and address a substantial weight loss in a timely manner for a resident with multiple medical conditions, including normal pressure hydrocephalus, diabetes, and frontotemporal neurocognitive disorder. The resident was observed refusing or not consuming meals, expressing dislike for the food, and not requesting alternatives. Despite these observations and a documented history of poor appetite and gastrointestinal issues, there was no evidence that the facility took appropriate action to assess or intervene regarding the resident's nutritional status during the period of weight loss. The clinical record showed that the resident experienced an 11.31% loss of body weight within 30 days, dropping from 194.6 pounds to 172.6 pounds. However, there was no documentation of a re-weigh to confirm the accuracy of this loss, nor was there evidence that the weight loss was reported to or evaluated by the dietary department or physician. Nutritional assessments completed after the weight loss failed to acknowledge or address the significant change, and progress notes from both the Certified Dietary Technician and Registered Dietitian did not reflect any investigation or intervention related to the weight loss. Interviews with facility staff revealed that discrepancies in weight documentation were attributed to errors by the staff responsible for weighing residents, but no formal evaluation or documentation was made to confirm whether the weight loss was genuine or erroneous. Additionally, the resident's care plan, which identified a risk for nutrition-related declines, did not include any new interventions following the documented weight loss. The facility's policy required monitoring and reporting of significant weight changes, as well as weekly monitoring for residents with weight loss, but these procedures were not followed. The lack of timely identification, assessment, and intervention for the resident's significant weight loss constitutes a failure to provide adequate nutrition and hydration to maintain the resident's health.