Failure to Address and Document Significant Weight Loss
Penalty
Summary
A resident with diagnoses including depression, muscle weakness, severe protein-calorie malnutrition, and type 2 diabetes mellitus experienced significant unplanned weight loss. The resident's weight dropped from 187.2 lbs. to 164.2 lbs. over a period of weeks, with a questionable weight entry on one date that was later crossed out by the Registered Dietitian (RD) due to suspected inaccuracy. The RD was not made aware of the significant weight loss that occurred prior to the resident's hospitalization, and there was no documentation that the physician was notified of this weight loss. The facility's policy required verification of significant weight changes, assessment by the dietitian, and physician notification, but these steps were not consistently followed or documented. Interviews revealed that the RD relied on nursing staff to input weights into the electronic medical record and to notify her of changes, but this communication did not occur as expected. The RD also stated that she typically notifies the physician of significant weight changes but does not always document this action. The Director of Nursing confirmed that the RD monitors weights and is responsible for physician notification, but there was no evidence that the required notifications or interventions were completed or documented for the resident's significant weight loss prior to hospitalization.