Failure to Address Significant Weight Loss and Nutritional Needs
Penalty
Summary
The facility failed to adequately monitor, implement, and modify nutritional interventions for two residents, resulting in unaddressed significant weight loss. For one resident with a history of lumbosacral and pelvic fractures, weight records showed a loss of 9.2 lbs (5.14%) over ten days, but there was no evidence of a required reweigh or timely dietary intervention. The resident's care plan, which already identified risk for malnutrition, was not updated to reflect the significant weight loss, and the dietitian did not assess the resident until after the weight loss had occurred. Another resident, admitted with multiple diagnoses including coronary artery disease, diabetes, malnutrition, and moderate cognitive impairment, experienced a weight loss of 15.2 lbs (12.7%) within one month. Despite repeated weight warnings and documentation indicating the need for a reweigh, there was no evidence that a reweigh was performed. The resident's dietary preferences were not met, and the care plan to provide oral nutritional supplements was not fully implemented. The dietitian was aware of the weight loss but had not completed a comprehensive assessment or documented interdisciplinary team notification. Both cases demonstrated a lack of adherence to the facility's own policies regarding weight monitoring, timely reweighs, and prompt dietary interventions. Documentation and staff interviews confirmed that significant weight changes were not properly addressed, and care plans were not updated to reflect the residents' changing nutritional needs.