Failure to Monitor and Document Resident Weight and Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to properly monitor and document the nutritional status of a resident diagnosed with dementia and severe protein-calorie malnutrition. According to facility policy, residents' weights are to be measured on admission, weekly for two weeks, and then monthly if no concerns are noted, with any significant weight change (5% or more) requiring a reweigh for confirmation and physician notification. For this resident, there was a significant weight loss of 8.7% over a short period, but the clinical record did not show that the physician was notified of this change. Additionally, there was no documentation of a reweigh to confirm the significant weight loss as required by policy. Further review revealed that monthly weights were not obtained or recorded for the resident in the months following the significant weight loss, despite a standing physician order for monthly weights. The Registered Dietitian reported a change in the process for notifying physicians of significant weight losses but was unable to provide evidence of notification for this resident. The DON confirmed that the treatment administration records for the relevant months were blank for the resident's weight order, indicating non-compliance with both physician orders and facility policy.