Failure to Timely Assess and Address Significant Weight Loss
Penalty
Summary
The facility failed to complete a comprehensive nutritional assessment and consistently monitor weights to identify and address significant weight loss for a resident with moderate calorie-protein malnutrition and dementia. According to facility policy, a weight change of 5% or more in one month requires a reweigh within 48 hours, reassessment by the dietitian, and care plan adjustments as needed. The resident experienced a 6.5% weight loss over a 33-day period, but there was no evidence of a timely reweigh, reassessment, or care plan revision following this significant change. The care plan, which already identified the resident as at risk for nutritional deficits, was not updated to reflect the new weight loss, and there was no documentation of physician notification or new interventions. Further review showed that the Registered Dietitian did not document the significant weight loss until over two months after it occurred, and at that time, no new interventions were recommended. The delay in identifying and responding to the resident's nutritional decline was inconsistent with the facility's policy and did not demonstrate timely reassessment or mitigation of nutritional risk. These findings were confirmed during an interview with the Nursing Home Administrator.