Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to adequately assess, monitor, and identify significant weight loss for one resident with multiple complex medical diagnoses, including partial traumatic amputation, acute osteomyelitis, vascular dementia, depression, anxiety disorder, and type 2 diabetes with a foot ulcer. The resident was identified as being at nutritional risk, with care plan interventions requiring at least monthly weights and reporting of significant weight changes to the physician and dietitian. Despite a dietitian's recommendation for ongoing weekly weights, the resident experienced an 8.54% weight loss over less than a month, and weekly weight monitoring was discontinued. The resident's weight continued to decline, reaching a total loss of 10.39% over a short period. The facility's policy required regular monitoring and interdisciplinary communication regarding significant weight changes, but these processes were not followed. The facility had been without a dietary manager for several months, relying on a contract dietitian working offsite only one day per week. Additionally, the required Diet History/Food Preferences Evaluation for the resident was 45 days overdue. These lapses resulted in a failure to promptly identify and address the resident's significant weight loss as required by facility policy and the resident's care plan.