Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to appropriately monitor and address significant weight changes for three residents, as required by its own policy. For one resident with Type 2 Diabetes and GERD, a significant weight loss of 10.4% over 18 days was recorded, but a re-weigh was not completed until two days later. There was no documentation that the physician was notified of this significant weight loss or that any interventions were implemented to address the issue. The Interim Director of Nursing confirmed that the physician was not notified and interventions were not put in place. Another resident with dementia and dysphagia experienced a 7.19% weight loss in seven days, with a re-weigh also delayed by two days. The clinical records did not show that the resident was assessed after the significant weight loss was identified, nor that the physician or dietitian was notified, or that any interventions were implemented. The dietitian confirmed not being notified of the weight loss, and the Interim Director of Nursing confirmed that the resident was not assessed and the physician was not notified. These failures demonstrate a lack of timely monitoring, assessment, and communication regarding significant weight changes.