Failure to Timely Respond to Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable parameters of nutritional status, as evidenced by the lack of timely response to significant weight loss. A resident with severe cognitive impairment and a history of dysphagia requiring a gastronomy tube experienced a weight loss of over 6% within 30 days. Facility policy required reweighing within 24 hours of a significant weight change and notification of the registered dietician, physician, family, and assessment coordinator. However, there was no documented evidence that the resident was reweighed within 24 hours after significant weight losses were identified on two separate occasions. Additionally, there was no documentation of a nutritional assessment being completed or of the physician or resident representative being notified following the significant weight loss events. The registered dietician confirmed that the significant weight loss was not reviewed until 10 days after it was identified, and that required notifications were not made. These failures were in direct violation of the facility's policies and state regulations regarding monitoring and responding to changes in residents' nutritional status.