Failure to Monitor and Intervene for Significant Weight Loss
Penalty
Summary
The facility failed to adequately monitor and implement timely interventions for residents experiencing significant weight loss. For three residents reviewed, there was a lack of consistent monitoring, including the failure to complete weekly weights as ordered after significant weight loss was identified. In one case, a resident with dementia and other chronic conditions experienced a 6.9% weight loss in 30 days and 8.2% in 90 days, but weekly weights were not performed and nutritional supplements were not ordered until a month after the weight loss was noted. Another resident with severe cognitive impairment and psychiatric diagnoses also experienced significant weight loss, with orders for house supplements and weekly weights not being followed. Despite physician orders for weekly weights and nutritional supplements, documentation showed that weekly weights were not completed as required. The care plan included interventions such as dietician evaluation and supplement provision, but these were not consistently implemented or documented. A third resident, with multiple chronic conditions including Alzheimer's and depression, had repeated episodes of significant weight loss over several months. Although care plans and progress notes indicated the need for increased monitoring, nutritional supplements, and weekly weights, there were gaps in weight documentation and delays in implementing interventions. Interviews with staff confirmed that weekly weights were not consistently performed and that documentation of a weight loss plan was lacking, even as the resident continued to lose weight.