Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
A deficiency occurred when the facility failed to maintain acceptable parameters of nutritional status for a resident with multiple complex medical conditions, including Type 2 Diabetes Mellitus, Congestive Heart Failure, Pressure Ulcers, Chronic Kidney Disease, and Muscle Wasting and Atrophy. The resident experienced a significant weight loss of 47 pounds (21%) over a two-month period. Despite physician orders for weekly weights and a care plan that included monitoring for signs of malnutrition and significant weight loss, the facility did not consistently obtain or document weekly weights as required. There were missed weight checks, and when the resident refused a weight, there was no documented follow-up or notification to the physician. Staff interviews revealed confusion and lack of clarity regarding responsibilities for obtaining, recording, and monitoring weights. The Restorative Aide (RA), who was primarily responsible for obtaining weights, was frequently reassigned to floor duties, resulting in missed weight checks. The process for entering weights into the electronic chart was also inconsistent, with only nurses or the DON entering the data. Alerts for missed weights were not consistently reviewed or acted upon by the DON or ADONs, and the Registered Dietitian (RD) was not reviewing orders to determine which residents required weekly weights, relying instead on weight variance reports that were not always up to date. Despite the resident's ongoing weight loss and the presence of interventions such as nutritional supplements and fortified diets, there was no timely reassessment or adjustment of the weight monitoring schedule. The lack of communication and follow-through among nursing staff, the RD, and the DON led to a failure to recognize and address the resident's significant weight loss in a timely manner. There was also no documentation that the physician was notified of the resident's weight loss or refusals, and the care plan was not updated to reflect the need for continued weekly weights.