Failure to Provide Timely Dietician Evaluation for Significant Weight Loss
Penalty
Summary
A resident with multiple complex medical conditions, including diabetes mellitus, dysphagia, anemia, heart failure, and chronic kidney disease, experienced a significant and rapid weight loss over a short period. The resident's care plan identified high nutritional risk factors, such as malnutrition, increased nutrient needs, and the presence of chronic wounds. Despite documented weight losses of 5% in one month, 7.6% in two weeks, and 13% in three weeks, there was a delay in obtaining a timely dietician evaluation to address these changes. The dietician last evaluated the resident on 5/6/2025 and did not reassess until 6/3/2025, despite the weight loss being evident in the facility's records and weight reports. Facility policy required that significant weight changes be verified, reported to the interdisciplinary team, and the care plan revised as appropriate. The dietician relied on weight reports and notifications from nursing staff to identify residents needing evaluation but did not recall noticing the resident's significant weight loss in the reports. The DON confirmed that a weight change of 5% or more should have triggered immediate notification and evaluation by the dietician, which did not occur. The facility did not have a specific policy addressing the timing of dietician evaluations for significant weight loss.