Failure to Follow Policy for Significant Weight Loss Notification
Penalty
Summary
The facility failed to follow its own policy regarding the management of significant weight loss in residents. Specifically, for one resident with multiple diagnoses including anemia, malnutrition, dysphagia, and multiple pressure ulcers, the facility did not re-weigh the resident after a weight loss of 5% or more, nor did they immediately notify the Registered Dietitian (RD) in writing as required by their policy. The resident experienced several instances of weight loss exceeding 5% within one-week intervals, but there was no documentation that the RD was notified in writing, and the process for re-weighing and written notification was not followed. Interviews with facility staff confirmed that the current practice was to notify the RD verbally rather than in writing, and that the policy for re-weighing and written notification was not being implemented. The DON acknowledged that the facility's actual process did not match the written policy. As a result, the resident experienced increased weight loss, worsening malnutrition, delayed medical treatment, and slower healing of pressure sores, as directly stated in the report.