Failure to Prevent Severe Weight Loss and Incomplete Weekly Weights for New Admission
Penalty
Summary
The facility failed to prevent severe weight loss in one resident and did not complete required weekly weights for a new admission. One resident experienced a 9% weight loss in one month, dropping from 132 lbs. to 120 lbs., despite being identified as nutrition at risk (NAR) and having a diagnosis of malnutrition and wounds. Staff interviews revealed that the resident was receiving supplements and was under supervision during meals, but there were issues with meal assistance, care plan updates, and consistent monitoring. The resident had a history of progressing dementia, difficulty swallowing, and required speech therapy, with documentation indicating that weekly weights were ordered but not consistently obtained. Another resident, who appeared thin and frail and was receiving oxygen, was not weighed weekly for four weeks after admission as required by facility policy. The resident reported a decreased appetite and was provided with nutritional supplements, but did not always consume them. Review of the medical record showed only one documented weight during the initial four-week period, contrary to the facility's policy that mandates weekly weights for new admissions to establish a baseline.