Failure to Timely Identify and Assess Significant Weight Loss
Penalty
Summary
The facility failed to promptly identify and assess a resident who experienced significant weight loss. The resident, who had severe cognitive impairment and multiple diagnoses including senile degeneration of the brain, cancer, and atrial fibrillation, was noted to have lost 6.72% of body weight in one month, dropping from 126.5 pounds to 118 pounds. The care plan in place required daily monitoring and recording of food and fluid intake, as well as regular weight checks and dietary supplements as ordered. Despite these interventions, the significant weight loss was not immediately recognized or addressed by the staff. Staff interviews revealed uncertainty about the accuracy of the resident's weight, and a reweight was not obtained promptly after the initial low measurement. The facility's nutrition policy required evaluation by the Interdisciplinary Team for any resident with a weight change of 5% in 30 days, but this process was not followed in a timely manner. Observations showed that the resident was eating with some assistance and consuming supplements, but the necessary assessment and intervention for the weight loss were delayed.