Failure to Accurately Document Significant Weight Loss in Resident Assessments
Penalty
Summary
The facility failed to conduct accurate comprehensive assessments of two residents' functional capacity, specifically regarding significant weight loss. For one resident with metabolic encephalopathy, dependence on renal dialysis, and end stage renal disease, medical records showed a weight loss from 118 lbs. to 109.2 lbs. within a little over a month, amounting to a 7.46% decrease. Despite this, the resident's Quarterly MDS assessment did not reflect the weight loss under Section K - Swallowing/Nutritional Status. The resident's care plan did note unplanned weight loss and included interventions such as dietary supplements. Similarly, another resident with sepsis, encephalopathy, and type 2 diabetes experienced a weight loss from 242 lbs. to 225.4 lbs., a 7% decrease, but the Quarterly MDS assessment did not indicate this significant weight loss. The care plan for this resident also documented unplanned weight loss and included interventions like alerting the dietician and notifying the physician if further weight loss occurred. The MDS Coordinator confirmed during interview that the significant weight loss for both residents should have been documented in their respective MDS assessments.