Failure to Monitor and Address Resident Weight Loss
Penalty
Summary
The facility failed to properly monitor and document the nutritional status of a resident with diagnoses including muscle wasting, dysphagia, and depression. According to facility policy, residents are to be weighed upon admission and at intervals set by the interdisciplinary team, with any significant weight change requiring confirmation and immediate notification of the dietitian. For this resident, physician orders specified weekly weights for four weeks following admission. However, the clinical record did not show that weights were obtained and documented on two of the required weeks. The resident experienced a significant unplanned weight loss of 7.8% over one month, which was not identified or addressed in a timely manner due to the missed weight checks. Further review revealed that, although the significant weight loss was eventually confirmed, the resident's care plan was not updated to reflect the weight loss or to include nutrition interventions in response. Staff interviews confirmed that the expectation was for weights to be obtained as ordered, reweighs to be performed for confirmation, and care plans to be updated accordingly. The lack of timely monitoring, documentation, and care planning contributed to the failure to maintain the resident's nutritional status within acceptable parameters.