Failure to Comprehensively Assess and Address Resident Weight Loss
Penalty
Summary
The facility failed to comprehensively assess and develop interventions to prevent or reduce continued weight loss for a resident with severe cognitive impairment and dementia. The resident experienced significant unplanned weight loss over a three-month period, with documented weights showing a decline from 104.8 lbs. to 87.6 lbs., representing a 16.41% loss. Despite a care plan identifying unplanned weight loss and interventions such as referral to a dietician, meal assistance, and monitoring of food intake, the resident's medical record lacked evidence of a comprehensive assessment addressing the ongoing weight loss. Observations revealed that the resident had difficulty eating independently, particularly with certain food textures, and required significant prompting and assistance from staff. Staff interviews confirmed that the resident struggled with chewing and needed frequent reminders and coaching to eat. The resident was served food that did not always match the ordered diet texture, and staff sometimes delayed assistance at meals. The dietary manager and consultant dietician communicated about the resident's weight loss, but a comprehensive nutritional assessment was not completed, and recommended referrals, such as for a speech evaluation, were not initiated. The facility's policy required a thorough nutritional assessment, including review of diet, oral status, lab values, medications, and other relevant factors, but this was not completed for the resident. The consultant dietician acknowledged that comprehensive assessments had not been kept up to date, and the dietary manager had not implemented a more detailed assessment form provided by the dietician. The lack of a comprehensive assessment and timely interventions contributed to the resident's continued weight loss and inadequate management of her nutritional needs.