Failure to Monitor and Address Significant Weight Changes
Penalty
Summary
The facility failed to adequately monitor and address significant weight changes for two residents. For one resident with a diagnosis of gastroesophageal reflux disease, physician orders required weekly weights, but after a 6.2% weight loss was recorded over a two-week period, there was no evidence of a reweight being performed or that the facility dietitian was notified of the weight loss. The clinical record did not show any follow-up or intervention in response to this significant change. Another resident, diagnosed with localized edema and dementia, experienced a 14.25% weight loss over a two-month period. The clinical records and nutrition assessment did not indicate that this significant weight loss was identified or that any interventions were implemented to address it. Interviews with the dietitian confirmed that no reweight was obtained for the first resident and that the dietitian was not notified of the weight loss for either resident.