Failure to Address and Document Significant Unplanned Weight Loss
Penalty
Summary
A resident with Parkinson's Disease experienced a significant unplanned weight loss, dropping from 133.5 lbs to 111 lbs over a 37-day period, representing a 16.9% decrease. Meal intake records showed variable consumption, and although a dietary note confirmed the weight loss and recommended providing nutritious dessert cups twice daily, there was no documentation that these were offered or consumed. The clinical record also lacked evidence that the resident's physician and representative were notified of the significant weight loss, as required by professional standards and regulatory guidance. Further review revealed that after the significant weight loss was identified, the facility did not obtain weekly weights or conduct a nutritional assessment between the time of the weight loss and a later date. Interviews with facility staff, including the Registered Dietician and the DON, confirmed that the weight loss was not addressed in a timely manner, and the facility could not provide a written policy for monitoring and managing residents' nutritional status. No documentation was available to show that any interventions were implemented to address the resident's weight loss.