Failure to Assess and Intervene for Significant Weight Loss
Penalty
Summary
The facility failed to properly assess, evaluate, and monitor the nutritional status of two residents who experienced significant weight loss. For one resident with dementia and COPD, there was a documented pattern of frequent loose stools attributed to medication side effects and rectal prolapse. Despite ongoing documentation of these symptoms and a notable weight loss of 14 pounds (11%) over 90 days, there was no evidence that the physician or nurse practitioner evaluated or addressed the repeated episodes of loose stools, nor were adjustments made to the medication regimen. The resident's meal intake was inconsistent, and although nutritional supplements were provided, the underlying causes of weight loss were not adequately investigated or managed by the clinical team. For another resident with Alzheimer's Disease and adult failure to thrive, a significant weight loss of 19.2 pounds (10.53%) was recorded over a one-month period. The facility did not reweigh the resident within 24 hours as required by policy, nor did they notify the physician, resident representative, or Dining Services Director of the weight loss. There was also no documentation that the resident's nutritional status was reviewed or that any interventions were recommended by the Dining Services Director or other members of the multidisciplinary team. These deficiencies were confirmed through staff interviews and review of facility records, which showed a lack of timely assessment, notification, and intervention in response to significant changes in residents' weights. The facility did not follow its own policies regarding weight monitoring, assessment, and communication, resulting in inadequate evaluation and support for residents experiencing significant weight loss.