Failure to Monitor and Report Severe Weight Loss
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status and did not consult with the resident's physician regarding significant weight loss for one resident. The resident, who had diagnoses including a lumbar fracture, CHF, cognitive communication deficit, and type 2 diabetes, experienced a severe weight loss of 15.3% over two months. Physician orders required daily weights due to CHF, with instructions to notify the nurse practitioner if there was a weight gain or loss of 3 lbs. in a day or 5 lbs. in a week. However, the medical record and MAR showed that weights were not consistently obtained daily as ordered, with some days marked as refused, held, or referencing progress notes. The resident's weight dropped from 280 lbs. to 238 lbs. over three months, a loss of 43.4 lbs., which is classified as severe. The Director of Nursing (DON) confirmed awareness of the daily weight order and acknowledged that the physician should have been notified of the severe weight loss and refusals. There was no documentation that the physician or nurse practitioner was updated about the weight loss or refusals, nor was there evidence that the risks and benefits of refusing weights were explained to the resident. The facility's policy required immediate notification of the dietician and physician for significant weight changes, but these steps were not documented or followed in this case.