Failure to Assess and Address Significant Weight Loss
Penalty
Summary
A significant weight loss in a resident was not properly assessed by the facility's dietitian, despite the resident being at high risk due to multiple medical conditions including dysphagia, diabetes, chronic heart failure, chronic kidney disease, and dementia. The resident was dependent on staff for eating, had varied meal intakes, and was on a mechanically altered therapeutic diet. The care plan required notification of the dietitian and physician in the event of significant weight change. The initial nutrition assessment was completed, but the resident's usual body weight was not documented, and estimated nutritional needs were not fully met by the prescribed diet and supplements. Subsequent weight records showed a dramatic and unexplained weight loss, with no follow-up assessment or documentation by the dietitian to address or determine the cause of the weight loss. The dietitian acknowledged not assessing the weight loss or notifying the physician, and there was no documentation in the medical record regarding the significant weight change prior to the resident's discharge. Additionally, the facility's weight policy did not specify when significant weight loss should be documented, contributing to the lack of appropriate response.