Failure to Identify and Address Significant Weight Loss
Penalty
Summary
A deficiency occurred when the facility failed to identify a significant weight loss in a resident, notify the physician, and ensure timely follow-up by the Registered Dietitian (RD). The resident, who had a history of stroke, diabetes, contractures, and GERD, was moderately cognitively impaired and required set-up assistance for eating. The resident's weight dropped from 222.4 lbs to 207.0 lbs within a short period, representing a significant weight loss, but there was no documentation of physician notification or intervention in the clinical record. Observations revealed that the resident often ate in a reclined position without staff assistance or repositioning, despite requiring help due to physical limitations. Staff interviews indicated that the resident sometimes refused meals due to fatigue or preference, and experienced oral secretions and occasional coughing during meals. However, there was no evidence that these issues were addressed or that additional nutritional support was provided during the period of weight loss. The facility's policy required re-weighing residents and notifying the RD and physician when significant weight changes occurred. Despite this, the RD did not implement interventions or request a reweight until much later, and the facility did not act promptly to address the resident's weight loss. The lack of timely identification, notification, and intervention contributed to the deficiency.