Failure to Address Significant Weight Loss and Notify Clinical Staff
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident who experienced a significant weight loss. According to the facility's own policy, licensed nurses are required to monitor and document weights, review significant weight changes, and notify the physician and dietitian when such changes occur. The resident, admitted with diagnoses including sepsis and diabetes mellitus, was identified as being at nutritional risk and had a physician's order for weekly weights. Despite this, the resident experienced a 6.7% weight loss over a short period, with weights documented almost daily showing a consistent decline. There was no evidence in the record that any nutritional intervention was implemented in response to the weight loss. Interviews with the Registered Dietitian and the resident's physician revealed that neither was aware of the significant weight loss, and the dietitian stated she would have intervened if notified. The Assistant Director of Nursing confirmed that the facility's computer system is designed to trigger alerts for significant weight loss, which should prompt a reweigh and further assessment, but this process was not followed for the resident in question.