Failure to Timely Identify and Address Significant Weight Loss
Penalty
Summary
The facility failed to identify and address a significant weight loss in one resident who was severely cognitively impaired and dependent on staff for meals. Despite facility policy requiring referral to a dietitian for weight changes of 5% in one month or 10% in six months, the resident experienced an 8% weight loss over approximately two months. The resident's weight dropped from 126.3 lbs to 116.2 lbs between late December and late February, but the dietitian was not notified or did not assess the resident for this weight loss until early April, 39 days after the significant loss was first documented. During this period, the resident was prescribed nutritional supplements and appetite-stimulating medication, but there was poor acceptance of oral nutritional supplements and variable meal intake. Staff interviews revealed a lack of awareness of the resident's weight loss among CNAs and a reliance on electronic reports for communication between nursing and the dietitian, with minimal verbal communication. The dietitian stated she was unaware of the significant weight loss in February and had not assessed the resident until April. The delay in assessment and intervention was attributed to missed recognition of the weight loss in the electronic reporting and lack of timely communication between staff and the dietitian.