Failure to Monitor and Communicate Significant Weight Loss in Two Residents
Penalty
Summary
The facility failed to ensure proper monitoring and maintenance of nutritional status for two residents, resulting in deficiencies related to weight monitoring and timely notification of significant weight loss. For one resident with chronic kidney disease, vascular dementia, and a history of failure to thrive, there were physician orders for monthly weights and tube feedings. However, weight documentation was missing for several months, and the resident experienced a significant weight loss of 24 pounds in June, which was not communicated to the physician, hospice provider, or family. Additionally, no nutritional assessments were completed by the facility dietician for an extended period, and the hospice and facility staff did not document or address the weight loss until months later, despite ongoing tube feedings and changes in the resident's oral intake. Another resident with a history of infection, dysphagia, and repeated falls reported weight loss due to receiving food that was not suitable for his needs or preferences. The care plan included interventions for regular weight monitoring and notification of significant changes to the medical doctor and dietitian. Despite physician orders for daily, weekly, and then monthly weights, there was a gap in weight documentation, and a significant weight loss of 5.1% was recorded over a two-week period. The facility obtained a reweigh after noticing the discrepancy, but the reweigh was not completed within the expected timeframe. Interviews with the DON revealed that the facility's weight policy was not aligned with current professional standards, and staff did not consistently follow physician orders for weight monitoring. The DON acknowledged that residents on hospice should still have been weighed according to orders and that significant weight loss should have been communicated to the appropriate providers and representatives. The lack of timely documentation, assessment, and communication contributed to the deficiencies identified for both residents.