Failure to Address Significant Weight Loss in Resident
Penalty
Summary
A resident with multiple complex medical conditions, including myasthenia gravis, dementia, gastroparesis, and paraplegia, experienced significant weight loss over several months following admission. The resident's weight dropped from 165 lbs at admission to 133 lbs, representing a 19.39% decrease. Despite this notable weight loss, the medical record showed no evidence of interventions being implemented to address the issue, nor were there any progress notes or assessments by the dietician or nursing staff regarding the weight loss. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's weight loss. The DON was not aware of the situation, and the dietician, who is responsible for monitoring weights, did not know why interventions were not initiated. Although a therapy referral slip was completed by an LPN noting the weight loss, it is unclear if this information reached the dietician. The resident reported not receiving enough food and expressed dissatisfaction with the meals. The facility's policy requires maintaining residents' nutritional status, but this was not followed in the resident's case.