Failure to Monitor Weight Weekly After Significant Weight Loss
Penalty
Summary
The facility failed to follow its weight management policy for one resident who experienced significant weight loss. According to the resident's records, there was a loss of 17 lbs. between December 2024 and January 8, 2025, and a further loss of 13 lbs. by February 4, 2025. Despite this severe weight loss, there was no documentation of weekly weight monitoring after the initial loss was identified, as required by the facility's policy. The policy states that any weight change of 5% or more should prompt a retake the next day for confirmation and weekly monitoring thereafter. The deficiency was confirmed through record review and interview with the DON, who acknowledged that the resident should have been weighed at least weekly following the observed weight loss. The resident had diagnoses including muscle wasting and atrophy, making weight monitoring particularly important. The lack of weekly weight documentation after the significant weight loss was a direct violation of the facility's established procedures for weight assessment and intervention.