Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
A deficiency occurred when the facility failed to adequately monitor and address the nutritional status and weight of a resident with a history of epilepsy, gastrostomy, and dysphagia, who was dependent on staff for care and had a G-tube for enteral nutrition. Upon admission, the resident weighed 173.6 lbs, but within a week, a significant weight loss of 9.4 lbs (5.4%) was documented. The dietitian recommended nutritional supplements and an appetite stimulant, but there was no evidence that the stimulant was started, and no follow-up weights or nutritional assessments were performed in the subsequent weeks. After a hospitalization and readmission, the resident's weight continued to decline, with a further loss of 21 lbs (12.1%) since admission. Despite this, there were no documented weights or nutritional assessments for the entire month following readmission, and the care plan was not revised to address the ongoing weight loss. Interviews revealed that the facility lacked consistent, in-person dietitian coverage, with periods of only remote coverage and uncertainty among staff about who was responsible for nutritional oversight. Staff also reported that diet slips and diet change forms were not being signed off by a dietitian for newly admitted residents. Facility policy required weights to be obtained on admission and monthly, with additional monitoring and interventions for significant weight changes. However, the resident did not receive the required monitoring or timely interventions after multiple episodes of significant weight loss. Interviews with staff and the resident confirmed that weight monitoring was inconsistent, and the lack of dietitian presence contributed to the failure to reassess and update the nutritional care plan as required.