Failure to Monitor and Report Significant Weight Loss in Multiple Residents
Penalty
Summary
The facility failed to ensure proper monitoring and documentation of residents' nutritional status, specifically regarding the monitoring of weights as ordered by physicians and timely notification of significant weight loss to physicians. Facility policy required residents to be weighed at intervals established by the interdisciplinary team, with significant weight changes to be evaluated and communicated to the physician and multidisciplinary team. However, for four residents, there were lapses in following these protocols, including missed weekly weight measurements and lack of physician notification after significant weight loss. One resident with multiple diagnoses, including diabetes, schizophrenia, and dysphagia, had an order for weekly weights due to prior weight loss, but these weights were not obtained or documented because the order was not entered into the electronic record. Another resident with dementia and dysphagia experienced a significant weight loss over a month, but there was no documentation that the physician was notified, and recommended weekly weights were not consistently obtained due to a transcription error. Additionally, a reweigh measure was missed in the dietitian's assessment because it was not properly recorded in the electronic health record. A third resident with dementia and muscle weakness had a significant weight loss, but again, there was no documentation of physician notification or evidence that weekly weights were obtained as ordered. The fourth resident, with bipolar disorder and dementia, experienced substantial weight loss over several months, but the clinical record did not show that the physician was notified of these changes. In all cases, interviews with the Nursing Home Administrator confirmed the lack of documentation and acknowledged that the expected procedures for monitoring and communication were not followed.