Failure to Recognize and Address Severe Weight Loss
Penalty
Summary
The facility failed to maintain acceptable parameters of nutrition for a resident who experienced a significant, unrecognized weight loss. The resident, admitted with multiple diagnoses including colon cancer, dehydration, post-surgical aftercare, anemia, vitamin D deficiency, and muscle weakness, lost 21.4 pounds (15.7% of body weight) over a 10-day period, and a total of 31.8 pounds (23.3% of body weight) over five weeks. This weight loss was not identified, addressed, or reported to the physician in a timely manner, as required by facility policy. Observations and interviews revealed that the Restorative Nursing Assistant (RNA) was responsible for weighing residents and documenting the results, with the expectation to notify the DON or ADON of any weight change of 3 pounds or more. However, the RNA did not recall notifying anyone about the resident's severe weight loss. Licensed nursing staff and the DON confirmed that there was no documentation of physician notification or change of condition related to the weight loss during the critical period. The resident was not weighed weekly as required, and the significant weight loss was not recognized until more than four weeks after it occurred. Further review with the Registered Dietician (RD) and Medical Director (MD) confirmed that the resident met the criteria for severe weight loss, but interventions were not implemented until more than a month after the initial documented loss. The facility's own policies required prompt notification of significant changes in condition and unplanned weight loss, but these procedures were not followed. The delay in recognition and intervention was attributed in part to staff transitions, including changes in DON and RD positions during the period in question.