Failure to Monitor and Address Significant Weight Loss in Residents
Penalty
Summary
The facility failed to follow its own weight monitoring policy and did not ensure proper nutritional interventions for two residents experiencing significant weight loss. For one resident with diagnoses including COPD, vitamin deficiency, GERD, hyperlipidemia, and schizophrenia, there was a documented weight loss exceeding 5% in one month and over 10% in six months. Despite this, there was no evidence that the physician, Registered Dietitian, or Dietary Manager were notified as required by policy. Additionally, staff did not monitor the resident's weight weekly, and the care plan was not updated to address the ongoing weight loss. The resident reported requesting double portions for several months without success, and interviews revealed that staff were unaware of these requests and did not implement additional interventions. Another resident with dementia and psychotic disorder, who required assistance with eating, also experienced significant weight loss—over 14% in six months. Physician orders for nutritional supplements such as Magic Cup and health shakes were not consistently documented or provided. Observations showed that the resident was not served the ordered supplements during meals, and staff interviews confirmed a lack of awareness and communication regarding supplement orders. The dietary and nursing staff did not coordinate to ensure the supplements were administered, and the care plan did not reflect the physician's orders or address the resident's weight loss. In both cases, there was a lack of weekly weight monitoring, failure to notify appropriate clinical staff of significant weight changes, and inadequate documentation and implementation of nutritional interventions. The deficiencies were confirmed through record reviews, staff and resident interviews, and direct observation, all indicating that the facility did not adhere to its policies for monitoring and addressing weight loss in residents.