Failure to Monitor and Address Significant Weight Loss in a Resident
Penalty
Summary
A deficiency occurred when the facility failed to adequately monitor and address the nutritional status of a resident with significant weight loss. The resident, who had multiple diagnoses including dementia, Parkinson's disease, chronic kidney disease, muscle weakness, and dysphagia, was identified as being at risk for nutritional problems. Despite this, there were inconsistencies and gaps in the documentation of the resident's weights, with several periods lacking recorded weights or care management notes. Notably, there were significant fluctuations in the resident's recorded weights, including a drop from 178 pounds to 166.9 pounds within a month, and later a drastic decrease to 103.6 pounds, with some weights suspected to be inaccurate but not verified or clarified in the record. The care plan and dietary notes indicated that the resident was to be monitored for weight changes and provided with appropriate dietary interventions. However, the clinical record lacked timely documentation of interventions in response to the resident's weight loss, such as the initiation of supplements or changes in diet. There were also delays in updating care plans and implementing interventions like health shakes and fortified foods, with orders for supplements not being entered into the electronic health record until much later, despite being dated earlier. The interdisciplinary team did not consistently document reassessment or adjustment of interventions in response to ongoing weight loss. Interviews with staff revealed a lack of awareness regarding the resident's weight loss, and the facility's policy for monitoring new admissions was not consistently followed. The resident required assistance with eating, but this need was not always reflected in the care documentation. The failure to consistently monitor, document, and intervene in the resident's nutritional status led to unaddressed and significant weight loss over several months.