Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident, resulting in significant weight loss and ultimately death. Upon admission, the resident, an eighty-four-year-old female with diagnoses including adult failure to thrive, right femur fracture, and recurrent depressive disorders, was not weighed as required by facility policy. The facility also failed to obtain weekly weights for the first four weeks after admission, which prevented timely identification of a 10.39% weight loss over a 25-day period. There was no documentation that the resident refused to be weighed during her stay. The registered dietitian (RD) recommended nutritional supplements after observing the resident's refusal to eat, but the order for supplements was not placed until nearly a month later. During this time, the resident continued to experience poor intake and weight loss. The delay in implementing the RD's recommendations was due to a breakdown in communication and unclear delegation of responsibilities among staff, including the DON, ADON, and other nursing personnel. Interviews revealed that staff were either unaware of their responsibilities or did not follow through with required actions, such as entering weights into the electronic medical record and ensuring timely dietary interventions. Facility policy required residents to be weighed on admission and weekly for four weeks, with monthly weights thereafter, and for significant weight loss to trigger further interventions. However, these procedures were not followed for this resident. The lack of timely weights and delayed implementation of nutritional interventions meant that the resident's significant weight loss was not addressed promptly, and appropriate care planning and interventions were not initiated in accordance with facility policy.