Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to monitor and address significant weight loss for one resident who experienced a 28-pound decrease within two days of admission, followed by an additional 3-pound loss over the next three days. Despite facility policy requiring weights to be retaken and verified when a significant change is noted, and immediate notification of the dietitian and physician, there was no documented evidence that the resident's weight loss was reassessed, communicated to the physician, or that any follow-up occurred. The resident's medical record did not contain an assessment or monitoring for the significant weight loss, nor was there documentation explaining the reason for the drastic change. The care plan for the resident identified a nutritional problem and risk for weight fluctuation due to dialysis and refusal of treatment, with a goal to prevent significant weight loss or gain. However, the care plan did not specify what constituted significant weight change for this resident. During interviews, the DON acknowledged the lack of documentation and monitoring following the weight loss event. The resident was observed to have a good appetite and food preferences were met, but reported a lack of appetite at meal times.