Failure to Timely Reweigh and Report Significant Weight Loss
Penalty
Summary
The facility failed to act promptly on the Registered Dietitian's (RD) recommendation to reweigh a resident after a significant weight loss was identified. The RD had recommended a reweight and an increase in nutritional supplements after noting a 13.6% weight loss in one month. Although the diet order was revised to increase calories and supplement volume, the reweight was not performed until several days later, and the result was neither documented in the medical record nor reported to nursing management until more than two weeks after it was obtained. This delay prevented timely recognition and intervention for the resident's ongoing weight loss. The resident involved had multiple diagnoses, including dementia, hypothyroidism, nutritional deficiency, and protein-calorie malnutrition. She was noted to have severe cognitive impairment and required setup and clean-up assistance with eating. Despite her significant weight loss and poor oral intake, there was no evidence that her nutritional status or lack of eating was discussed by the interdisciplinary team or reported to the physician. During meal observation, the resident did not consume any food independently, and staff did not provide cues or encouragement to eat, even though she typically required such assistance. Interviews with facility staff revealed lapses in communication and follow-through regarding the resident's weight monitoring. The Assistant Director of Nursing (ADON) acknowledged responsibility for ensuring weights were completed but did not follow up in a timely manner. The Unit Clerk obtained the reweight but failed to enter it into the medical record or notify the ADON. The RD and Medical Director were not informed of the significant weight loss, and the Medical Director stated he would have taken further action if notified. The Director of Nursing (DON) and Administrator both indicated that reweights and documentation should occur promptly, but this did not happen in this case.