Failure to Timely Address Significant Weight Loss
Penalty
Summary
A deficiency occurred when the facility failed to timely address a significant weight loss in a resident with multiple complex medical conditions, including schizophrenia, severe sepsis with septic shock, adrenocortical insufficiency, depression, and thyrotoxicosis. The resident's care plan identified altered nutritional status and significant weight loss, with interventions such as monitoring intake, providing supplements, and alerting nursing or dietitian staff if intake was inadequate. Despite these interventions, the resident experienced a substantial weight loss over a short period, dropping from 192 pounds to 146 pounds between early May and July, as documented in both facility and hospital records. The facility's records showed that the resident's weight was stable until early May, after which there was a marked decline. The resident was hospitalized for altered mental status, and hospital records confirmed a significant weight loss during the stay. Upon return to the facility, further weight loss was documented, but there was no timely documentation or intervention addressing the ongoing weight loss between May and July. The quarterly nutritional assessment did not reflect the hospital or recent facility weights, and incorrectly noted no significant weight loss, despite meal intake averaging only 50% and the resident refusing supplements. Interviews with staff revealed that standard procedures for monitoring significant weight loss, such as obtaining reweights and initiating weekly weights, were not followed in a timely manner. The dietitian and DON confirmed that the resident's weight loss was not addressed promptly, and the facility's policy requiring reweights within 48 hours of a five-pound deviation was not implemented. The lack of timely assessment and intervention contributed to the resident's continued decline, as evidenced by further weight loss and subsequent hospitalizations.