Failure to Identify and Address Significant Unplanned Weight Loss
Penalty
Summary
The facility failed to identify and address unplanned and significant weight loss in two residents, resulting in a deficiency related to maintaining adequate nutrition and hydration. One resident with a history of paranoid schizophrenia, muscle spasm, dementia, and dysphagia experienced a progressive weight loss from July through November, which was not recognized or addressed by staff. Interviews revealed that CNAs noticed the resident's declining intake and need for assistance with eating, but this information was not consistently communicated to licensed nurses or the interdisciplinary team. The DON and RD acknowledged that the weight loss should have triggered weekly weights, IDT discussion, and physician notification, but there was no documentation of these actions being taken. Another resident with metabolic disorder, iron deficiency, paraplegia, and gastrostomy status also experienced significant unplanned weight loss over several months. Staff observed the resident refusing meals and noted physical changes such as looser-fitting briefs, indicating weight loss. Despite these observations and a documented 13.7% weight loss over six months, the RD did not perform a comprehensive nutritional assessment, citing that such assessments were only done annually regardless of significant weight changes. Progress notes indicated continued monitoring but no substantial intervention until further weight loss occurred. Facility policies required monitoring for undesirable weight changes, prompt identification of causes, and comprehensive nutritional assessments upon significant weight loss or change in condition. However, these policies were not followed, as evidenced by the lack of timely assessment, intervention, and communication among staff and the IDT. The failure to implement a comprehensive, systemic approach to monitoring and addressing nutritional status led to the deficiency cited in the report.