Commander Nursing Center Cited After Two Residents Experience Significant Weight Loss

Commander Nursing Center in Florence, South Carolina was cited after the facility “failed to notify the physician and/or personal representative of significant weight loss” for two residents. The lack of notification resulted in each resident continuing to lose weight in an unhealthy manner over several months.

The first resident in this citation weighed 170 pounds. Over the course of 6 months, the resident’s weight dropped to 134 pounds, a 21% change in weight. According to the care plan, the resident was to receive AWC Prostat during meals. AWC Prostat is a liquid protein supplement used for medical care. Review of the Medication Administration Records (MAR) revealed the resident refused to take the AWC Prostat for 27 days. The investigator of the citation could not find evidence that the physician and responsible party were notified of the significant weight loss, or that the resident refused to take the AWC Prostat for nearly a month.

The investigator interviewed a Licensed Practical Nurse (LPN) who helped care for the first resident. The LPN confirmed there was no documentation regarding the weight loss. The LPN went on to say, “I told the physician and he (she) is aware but I did not document that anywhere in the medical record.” The Dietary Consultant also stated that they were not aware of the resident’s weight loss and refusal of AWC Prostat.

The second resident in this citation started at a weight of 200 pounds. Over the course of a month, the resident lost 15 pounds and continued to lose weight. After six months, they weighed 174 and had again experienced coffee ground emesis according to the physician’s notes. Coffee ground emesis is a type of vomit that looks like coffee grounds because there is old blood in the vomit. There was no evidence that the resident’s family was notified of the weight loss or repeated coffee ground emesis.

The facility has two policies in place in regards to a significant change in status and weight loss. The policy titled “Notification of Changes” states the following:

The facility must inform the resident, consult with the resident’s physician and/or notify the resident’s family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include: Significant change in the resident’s physical, mental or psychosocial condition such as deterioration in health status. This may include life-threatening conditions or clinical complications.

Each resident’s weight loss in this citation was a significant change in status. Both lost a lot of weight over a short period of time, and their families and physicians were never notified. In regard to weight loss, the facility has the following policy in place:

Based on the resident’s comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident’s clinical condition demonstrates that this is not possible or resident preferences indicate otherwise.

The residents in this citation did not maintain “acceptable parameters of nutritional status,” evidenced by their quick decline in health over time. The facility should have continued monitoring and weighing these residents and revising their care plans as necessary to keep the residents in good health.

In response to the citation, the facility began a weight monitoring program. An LPN was appointed as a Team Leader, and two Certified Nursing Assistants (CNAs) were put in charge of weighing all residents in the facility “as deemed necessary.” The Director of Nursing (DON) was tasked with closely monitoring the program and evaluating it weekly.

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