Failure to Address Significant Weight Loss in Resident
Penalty
Summary
A resident with diagnoses including Alzheimer's disease, diabetes mellitus type two, and bipolar disorder was admitted to the facility with a weight of 178 lbs. The resident was identified as being at risk for malnutrition, with care plan interventions to monitor weights and notify of any significant changes. Over the course of approximately one month, the resident experienced a significant weight loss of 18.43%, dropping from 178 lbs. to 145.2 lbs. Despite this notable change, there was no evidence in the medical record that the resident's physician was notified of the significant weight loss, as required by facility policy. The resident required set-up assistance and cueing for meals due to impaired cognition and was observed to consume a high percentage of meals. The registered dietician questioned the accuracy of the initial weight but still recommended continued weekly weight monitoring. Facility policy required the physician and multidisciplinary team to identify and address weight loss, but the lack of physician notification and absence of documented interventions addressing the weight loss constituted a failure to implement appropriate nutritional interventions for the resident.