Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to adequately maintain the nutrition and hydration status of a resident by not ensuring that significant weight loss was properly assessed and continually monitored. The resident, who had a history of anxiety, depression, and bipolar disorder and demonstrated moderate cognitive impairment, experienced a substantial decrease in weight over several months. Weight records showed a loss of 26.7% from February to May, with missing weight documentation for March and no evidence of reweighs or physician notification regarding the significant weight loss. Dietary notes indicated the resident triggered for weight loss on multiple occasions, but interventions were inconsistently applied, and the resident sometimes declined supplements. Interviews with facility staff revealed a lack of awareness and follow-up regarding the resident's weight loss. The nurse was unaware of the significant weight loss and did not know if the physician had been notified, while the Registered Dietitian expected nursing staff to identify and report significant changes. The DON confirmed expectations for monthly weights, reweighs, and notifications but was also unaware of the resident's weight loss and the lack of follow-up. The Medication Administration Reports did not indicate that the resident refused supplements, further highlighting gaps in monitoring and documentation.