Failure to Monitor and Address Resident Weight and Nutrition Status
Penalty
Summary
The facility failed to properly monitor and address the nutritional status and weight changes of four residents, as required by its own policies and physician orders. The policy specified that residents' weights should be obtained upon admission, weekly for the first four weeks, and monthly thereafter, or more frequently if at risk. However, clinical record reviews revealed that weights were either not obtained as ordered or significant weight changes were not acted upon or verified for accuracy. For example, one resident experienced a sudden weight gain of 29 pounds in one month, which was noted by a nurse practitioner but not addressed by the physician or registered dietitian. Another resident had a documented weight loss from 175 to 125.8 pounds over a short period, with no evidence that this loss was verified or evaluated by clinical staff. Additional residents also had inconsistent or missing weight documentation, with no follow-up or intervention from the physician or registered dietitian despite notable fluctuations. In several cases, weights were not recorded for scheduled intervals, and when significant changes were documented, there was no evidence in the clinical records that these changes were reviewed or that a plan of care was developed. Interviews with the medical director and registered dietetic technician confirmed that the facility did not consistently monitor or respond to weight changes for multiple residents. The residents involved had complex medical histories, including diagnoses such as diabetes, dementia, stroke, metabolic encephalopathy, COPD, anemia, and recent fractures. Despite these risk factors, the facility did not ensure that weights were obtained or that significant changes were addressed, as required by policy and physician orders. This lack of monitoring and intervention was confirmed by both clinical record review and staff interviews.