Failure to Address and Communicate Significant Weight Variances
Penalty
Summary
The facility failed to ensure staff adhered to professional standards regarding the monitoring and response to significant weight variances for a resident who was re-admitted after hospitalization with diagnoses including recurrent urinary tract infection and a stage IV decubitus ulcer. The resident experienced notable fluctuations in weight over a short period, including a 4% weight loss in two weeks and an 8% weight gain in two days. Despite these changes, there was no documentation that the weight variances were addressed by nursing staff or communicated to the Registered Dietician (RD), nor were they discussed in the Interdisciplinary Team (IDT) meetings during the relevant period. Interviews with staff revealed that while there was an expectation to re-weigh residents and notify the RD in cases of significant weight discrepancies, these actions were not documented or carried out for this resident. The RD confirmed she was not informed of the weight changes and emphasized the importance of being notified to review and adjust nutritional interventions, especially for residents receiving tube feeding. The Director of Nursing confirmed that the facility did not have a specific weight policy and instead followed the Lippincott procedure, which requires assessment and notification of practitioners for significant weight changes, but this protocol was not followed in this instance.