Failure to Maintain Nutritional Status and Adhere to Weight Monitoring Policy
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status, such as usual body weight, for two residents who experienced actual weight loss. Specifically, one resident with dementia was re-admitted and experienced a severe weight loss of 8.5% in less than one month, followed by continued weight loss in subsequent months. The Registered Dietitian assessed the resident but did not implement any interventions, citing a belief that the initial weight was an error, and there was no evidence that the resident was reweighed to verify this. Additionally, there was no documentation that the physician was notified of the severe weight loss, as required by facility policy, and further weight loss occurred without intervention. Another resident with type 2 diabetes and a history of weight loss experienced a 7.74% severe weight loss in less than one month. The care plan required weekly weights, but the facility failed to obtain weights as ordered and did not implement interventions or notify the physician after the significant weight loss. The facility's records did not show that weights were obtained upon admission or at the required weekly intervals, as per policy and physician orders. A third resident with a neurodegenerative disorder and dysphagia experienced a 5.5% weight loss, but the facility did not reweigh the resident after a 5 lbs. discrepancy as required by policy, and missed additional weekly weights as ordered. Interviews with staff, including the Director of Nursing Services and the Medical Director, confirmed that interventions were not implemented and that required weight monitoring and physician notifications were not completed. The facility failed to follow its own weight monitoring policy for three residents reviewed.