Failure to Monitor Weight Loss in Readmitted Resident
Penalty
Summary
A resident with a history of significant weight loss was readmitted to the facility following a hospitalization for enterocolitis due to clostridium difficile, cognitive and emotional deficits after a cerebral infarction, and type 2 diabetes mellitus. Upon review, it was found that the resident experienced a weight loss of 13.4 lbs (7.39%) between 04/11/2025 and 05/10/2025, and a further loss of 11 lbs (6.5%) by 5/30/2025. Despite this ongoing and severe weight loss, the facility did not obtain or document weekly weights for the resident after readmission, as required by facility policy. The Director of Nursing confirmed that the facility's policy mandates residents be weighed upon admission and then weekly for four weeks to establish baseline weight and monitor stability. The Registered Dietitian was aware of the resident's prior severe weight loss, but there was no documentation of continued weekly weight monitoring after the resident's return. This lack of monitoring prevented timely identification of further weight loss and the implementation of necessary interventions, constituting a failure to provide adequate nutritional monitoring for a resident at risk.