Failure to Monitor and Respond to Significant Weight Loss
Penalty
Summary
The facility failed to monitor and respond to significant weight loss for a resident with dementia who was at risk for altered nutritional status and poor appetite. The resident's care plan required that a nutritional supplement be offered if less than 50% of a meal was consumed, and that the Registered Dietitian (RD) monitor weights and oral intake. Despite these interventions, the resident experienced a weight loss of 12.93% over less than two months, with documented meal consumption often below 25%. Review of records and staff interviews revealed that significant weight losses were recorded on two occasions, but there was no documentation that the provider, RD, or Speech Language Pathologist were notified as required by facility policy. Staff interviews confirmed that the expected notifications and documentation did not occur, and the RD was unaware of the resident's weight loss. The deficiency was identified through observation, record review, and staff interviews, showing a lack of adherence to the facility's own policy for monitoring and responding to significant weight changes.