Failure to Address Severe Weight Loss and Document Interventions
Penalty
Summary
The facility failed to adequately address a severe weight loss in one resident by not following up on a recommended re-weigh, failing to document refusals, and not implementing dietary interventions. The resident's weight records showed a significant drop of over 10% within two months, with missing or refused weights documented for several months. Despite a registered dietitian noting dramatic weight loss and recommending a re-weigh, there was no follow-up documentation or evidence of further dietary intervention. Additionally, the resident's treatment administration record and nursing progress notes lacked consistent documentation of weight refusals or actions taken. Interviews with staff revealed that the resident frequently refused to be weighed and had a history of frustration with weight monitoring, especially after previous hospice care. Staff acknowledged that without a current weight, the nutrition at risk review system did not flag the resident for intervention. The resident, who had end-stage COPD and was on hospice, reported difficulty eating due to shortness of breath. No nutrition at risk meeting notes were available for the period in question, and the facility's tracking system failed to ensure appropriate follow-up for the resident's weight loss.