Failure to Prevent and Address Severe Unplanned Weight Loss
Penalty
Summary
A resident experienced severe unplanned weight loss totaling 29 pounds (18.59% of body weight) over a six-month period. The facility failed to implement multiple recommendations made by the Registered Dietician (RD), including weekly weight monitoring, administration of protein supplements, provision of double portions at breakfast, initiation of an appetite stimulant, and completion of blood tests for a complete metabolic panel and prealbumin. The resident's care plan, which required monitoring and reporting of weight loss and poor oral intake to the physician, was not followed. Additionally, the facility did not conduct weekly interdisciplinary team (IDT) weight variance meetings or develop a comprehensive care plan with interventions to prevent further weight loss. The resident had a complex medical history, including diabetes mellitus, kidney transplant, legal blindness, and gastro-esophageal reflux. Despite documented weight losses of 10 lbs., 8 lbs., 9 lbs., and 2 lbs. across several months, the facility did not complete required Change of Condition (COC) assessments or notify the physician and family as outlined in facility policy. The RD and nursing staff did not communicate or act on significant weight changes in a timely manner, and the resident's declining food intake and refusal of meals were not adequately addressed. The resident's family reported concerns about the facility's food and the lack of communication regarding the resident's weight loss. Interviews with facility staff, including the Assistant Director of Nurses (ADON), RD, and Director of Nurses (DON), confirmed that there were missed opportunities to identify and intervene in the resident's weight loss. The RD was unaware of the resident's weight loss until several months after it began, and recommended interventions were not implemented. Facility policies required prompt notification and multidisciplinary care planning for significant weight changes, but these procedures were not followed, resulting in the resident's continued and preventable weight loss.