Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to provide adequate care and services to address the nutritional status of a resident, as evidenced by not following its own weight monitoring policy and not addressing significant weight loss in a timely manner. According to facility policy, residents are to be weighed upon admission, weekly for four weeks, and then monthly, with more frequent assessments if indicated. However, the resident in question was not weighed on the day of admission or within 24 hours, and missed a weekly weight during the first month. The initial weight was recorded four days after admission, and a subsequent weekly weight was not documented as required by policy. Over the course of less than a month, the resident experienced a significant weight loss of 34 pounds, with documented weights showing a loss of 21 pounds in two weeks and a further decline the following week. Despite this, there was no documentation that the weight loss was reported to the physician, and the care plan meeting held during this period did not address the weight loss in detail. The care plan included monitoring for signs of malnutrition and reporting significant weight changes, but these interventions were not implemented as specified. Interviews with staff revealed a lack of clarity and consistency in the process for obtaining and documenting weights, as well as in the communication of significant weight changes to the appropriate clinical staff. The Registered Dietitian was not made aware of the significant weight loss until a week after it was documented, and interventions to address the weight loss were not initiated until several days later. The resident's family also reported difficulty obtaining updates on the resident's status during this period.