Failure to Investigate and Address Significant Weight Loss
Penalty
Summary
The facility failed to properly investigate and address significant weight loss in a resident with multiple medical conditions, including severe cognitive impairment, non-Alzheimer's dementia, schizophrenia, and dysphagia. Despite a documented 8% weight loss over three months, there was no evidence that the facility followed its own policy requiring immediate reweighing and notification of the dietitian when a significant weight change was identified. The resident's weights were inconsistently measured using different methods, and the Registered Dietitian (RD) noted that reweighing and a deeper investigation into the cause of weight loss should have occurred sooner. The resident was not provided with nutritional supplements despite consistently low meal consumption and no orders for supplementation were found in the medical record. The care plan identified the resident as being at risk for malnutrition and included interventions such as providing supplements and RD evaluation, but these interventions were not implemented. The RD confirmed that she had not recommended supplements because she was waiting for a reweight and further investigation, which had been delayed. Additionally, a psychotropic medication (Mirtazapine) was prescribed to address the resident's weight loss without prior evaluation or implementation of nonpharmacological interventions, and the RD was not consulted before this decision. Interviews with facility staff, including the RD, Nurse Practitioner (NP), and Director of Nursing (DON), revealed a lack of communication and process for identifying and responding to weight loss. The DON acknowledged there was no established process for identifying residents at risk for weight loss and was unaware of discrepancies in the resident's diet order and the absence of menu extensions for therapeutic diets.