Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable parameters of nutritional status, specifically regarding significant weight loss. The resident, who had multiple diagnoses including severe protein calorie malnutrition, chronic kidney disease, and legal blindness, experienced a weight loss of 10.1 pounds (6.61%) over three weeks. Despite facility policy requiring notification of the physician or registered dietician (RD) for significant weight changes, there was no evidence that either was notified or that new nutritional interventions were implemented. The resident's care plan identified them as at risk for impaired nutrition, and assessments indicated malnutrition and ongoing weight concerns, but no follow-up documentation or recommendations from the RD were found after the initial assessment. Additionally, the facility failed to maintain adequate documentation of the resident's meal intake, with over half of the meals served lacking any record of consumption. This lack of documentation made it impossible to accurately assess the resident's nutritional intake in relation to the observed weight loss. The surveyor confirmed these findings with facility leadership, who acknowledged the gaps in documentation and monitoring but did not provide further information prior to the survey exit.