Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to ensure that residents maintained acceptable parameters of nutritional status by not obtaining admission weights, failing to monitor weights consistently, inaccurately assessing residents for weight loss, and not implementing or monitoring nutritional interventions for multiple residents. Specifically, the facility did not obtain required admission or readmission weights for several residents, instead relying on hospital weights, which is against facility policy. In several cases, weights were not recorded within the required timeframe, and in some instances, no weight was obtained at all upon admission or readmission. For several residents, significant and severe weight loss occurred over short periods, with one resident losing 25.9% of body weight in three months, another losing 27.2% in three months, and another losing 9.41% in one month. The facility failed to identify and address these severe weight losses in a timely manner. There was a lack of documentation regarding meal consumption percentages, and recommendations from the Registered Dietician (RD) for interventions such as weekly weights, supplements, and fortified foods were not implemented or documented. In some cases, orders for nutritional supplements were delayed for days after the RD's recommendation, and there was no evidence of follow-up or reassessment after interventions were suggested. Interviews with facility staff, including the DON, RD, and Medical Director, revealed a lack of knowledge and communication regarding weight loss protocols, significant weight changes, and the implementation of recommended interventions. Staff were unaware of the significance of weight loss, did not hold regular weight meetings until recently, and failed to notify the physician or document interventions for residents experiencing significant weight loss. The facility's failure to accurately assess, monitor, and intervene for residents with significant weight loss resulted in Immediate Jeopardy for several residents.