Failure to Timely Complete Nutritional Assessments and Re-Weights for Significant Weight Gain
Penalty
Summary
The facility failed to timely complete nutritional assessments and obtain re-weights for a resident who experienced significant and continued weight increases. The resident, who had multiple diagnoses including chronic kidney disease, morbid obesity, type II diabetes, and other chronic conditions, showed a pattern of substantial weight gain over several months. Despite documented requests from the dietitian for re-weights following significant weight increases, these re-weights were not performed in a timely manner. For example, after a 5.6% weight increase in one month, a re-weight was requested but not completed until nearly a month later. Similarly, after another significant weight gain, a re-weight was again delayed by several weeks. Additionally, a full nutritional assessment was not completed after any of the significant weight increases, with the last assessment having been done months prior to the continued weight gains. Staff interviews confirmed that nurse aides obtain weights as directed by nursing staff, and that the dietitian relies on timely notification and completion of re-weights to perform further assessments. The facility's policy requires monthly weights and timely evaluation of significant weight changes by the multidisciplinary team, but these procedures were not followed. The dietitian confirmed that her requests for re-weights were not completed within her preferred timeframe, and that she was not notified promptly of significant weight changes. This resulted in a lack of timely intervention and assessment for the resident experiencing ongoing weight increases.