Failure to Assess and Intervene for Significant Weight Loss
Penalty
Summary
The facility failed to provide timely assessments and implement interventions to maintain acceptable nutritional status for a resident who experienced significant weight loss. According to facility policy, residents with a weight change of five pounds or more in a month should be reweighed within 24 hours, and if the change is validated as significant, the registered dietitian must assess the resident, investigate the cause, and determine necessary interventions. The policy also requires notification of the physician, charge nurse, family, and registered nurse assessment coordinator in the event of significant weight changes. Clinical record review showed that a resident experienced a 15-pound (6.79%) weight loss in one month, which met the facility's criteria for significant weight loss. However, there was no evidence that staff obtained a reweight, notified the physician, or conducted an assessment of the weight loss. Additionally, no interventions were documented to address the resident's nutritional status. The Nursing Home Administrator confirmed these findings and stated that the registered dietitian was no longer employed by the facility at the time.