Failure to Confirm Significant Weight Loss in a Resident
Penalty
Summary
The facility failed to reweigh a resident after significant weight loss was recorded on two separate occasions. According to the facility's policy, any weight change of five pounds or 5% or greater within 30 days requires a confirmation weight to be retaken the next day. However, the resident, who had diagnoses including multiple myeloma, cauda equina syndrome, and chronic kidney disease, was not reweighed after a 16.27% weight loss and a 7.48% weight loss were documented. Staff interviews confirmed that the reweighing procedure was not followed, and the weights were not confirmed as required. The resident in question was severely cognitively impaired and dependent on staff for all activities of daily living, including eating. Both the Restorative Nursing Assistant and the Director of Nursing acknowledged that the resident should have been reweighed to confirm the weight loss and to allow for timely notification of the physician and appropriate intervention. The failure to reweigh was contrary to the facility's written policy and could have resulted in improper management of the resident's nutritional status.