Failure to Identify and Address Significant Weight Loss
Penalty
Summary
The facility failed to identify, follow up, and adhere to its policy regarding significant weight loss for one resident with dementia who required staff assistance for all activities of daily living. The resident experienced a weight loss of 16.4 pounds in less than a month, as documented in the medical record. There was no evidence that a re-weight was performed to confirm the loss, nor was there any documentation of clarification of the recorded weight, notification to the dietician or physician, monitoring, or interventions or modifications to the resident's nutrition plan of care. The facility's policy required comparison of newly recorded weights to previous weights to determine if a re-weight was necessary, but this process was not followed. The DON confirmed that they were not notified of the weight loss and that therapy staff, who obtained the weights, did not inform them of the significant change.