Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to consistently monitor and document the weights of a resident with multiple diagnoses, including chronic obstructive pulmonary disease, frontotemporal neurocognitive disorder, generalized anxiety disorder, major depressive disorder, and vascular dementia. The resident was severely cognitively impaired and required varying levels of assistance with activities of daily living. Despite having a physician order for a no added salt diet and regular monitoring, the resident's weights were not consistently recorded for several months, including October, November, January, and March. This lack of consistent weight monitoring led to gaps in the resident's nutritional assessments. During the period in question, the resident experienced significant weight loss, dropping from 126.6 pounds to 87.8 pounds over several months. Nutrition notes indicated that the resident's oral intake varied, but no additional nutritional interventions, such as supplements or drinks, were implemented to address the weight loss. The registered dietician noted the need for reweighing due to suspected inaccuracies in the recorded weights and acknowledged that incomplete or missing weight data prevented the implementation of appropriate interventions. Interviews with facility staff, including the DON, RD, and physician, revealed a lack of awareness regarding the resident's significant weight loss and the inconsistent documentation of weights. The RD confirmed that inaccurate or missing weights were a recurring issue, and the physician stated she was not notified of the resident's weight loss or the failure to obtain weights consistently. The facility's policy required regular weight monitoring and intervention, but these procedures were not followed, resulting in the failure to address the resident's nutritional needs.