Failure to Monitor and Report Significant Weight Loss
Penalty
Summary
A deficiency was identified when a resident with dementia, protein-calorie malnutrition, and severe cognitive impairment experienced a significant unplanned weight loss of over fifteen percent in thirty days. The resident required maximal assistance with eating and was dependent on staff for nutrition. Documentation revealed that direct care staff did not consistently record the resident's meal intake, with numerous occasions where the amount eaten or the assistance provided was not signed off. There were multiple instances where the resident consumed only twenty-five percent or none of their meals, and there was no documented evidence that nursing or administration was informed of the resident's poor intake during this period. The facility's policy required systematic monitoring and timely management of significant weight loss, including regular documentation and communication with the physician and interdisciplinary team. Despite these requirements, the resident's declining intake and weight loss were not promptly identified or addressed due to lapses in documentation and communication. The registered dietician later confirmed the significant weight loss and noted the resident's ongoing challenges with eating, but this was only after the weight loss had already occurred and was brought to the attention of the interdisciplinary team.