Failure to Timely Address Significant Weight Loss
Penalty
Summary
The facility failed to ensure timely evaluation and intervention for a resident experiencing significant weight loss. According to facility policy, any weight change of five percent or more required immediate written notification to the dietitian, and physician orders required staff to monitor the resident's weight daily and notify the provider of more than two pounds of weight loss in one day or five pounds compared to the previous week. Despite these requirements, documentation showed that the resident experienced a weight loss of over six percent between 4/16/2025 and 4/21/2025, but there was no evidence that the provider or dietitian were notified as required. Progress notes did not reflect timely communication or intervention, and snacks were not implemented until five days after the nutritional risk assessment recommended them. The resident involved had diagnoses including congestive heart failure, dementia, gastric ulcer, and unilateral weakness, and required supervision or assistance with eating. Staff interviews confirmed that the required notifications were not made, with some staff unaware of the need to report weight loss, and others unsure of the reporting requirements. The lack of timely notification and intervention was contrary to both physician orders and facility policy, resulting in a delay in addressing the resident's nutritional needs.