Each resident or patient’s weight will be monitored consistently and closely by the interdisciplinary team. All residents with patterned or significant weight change will be assessed by the facility’s interdisciplinary team as indicated. Interventions to address nutritional issues will be initiated and incorporated into the resident’s care plan and re-evaluated on a timely and periodic basis.
- Upon admission to the facility, the nursing staff will weigh each resident, establish an accurate weight, and document the weight. The dietetics professional will determine ideal/desired body weight and document in the medical record.
- Weights are to be taken (by nursing staff) at least monthly, weekly, as ordered by the physician, or as outlined in the nutrition risk protocol. If a patterned or significant weight loss or gain is noted, the resident is to be re-weighed using consistent scale.
- Scales should be checked routinely for accuracy. Nursing staff is responsible for reviewing weekly weights, notifying appropriate disciplines of significant changes, initiating corrective actions, and completing documentation.
- In the event of a patterned or significant, unplanned weight loss/gain of at least 5% in 30 days, 7.5% in 90 days or 10% in 180 days, the following interventions will be carried out:
- Notification of attending physician and family member/responsible party by nursing staff.
- Notification of dietetics professional by nursing staff. The dietetics professional will assess the resident, document the assessment, and make recommendations in the resident’s medical record. Orders may be obtained for nutritional supplements or other interventions.
- Nursing staff will initiate a new MDS if indicated, schedule an interdisciplinary conference, and revise the care plan.
- The Director of Nursing is responsible for determining the need for initiation or discontinuation of weights other than weekly or ordered by physician.
- Request lab work if necessary.
- Nursing will initiate a 3-day calorie count.
- If the resident’s weight significant loss/gain is explainable (i.e., weight reduction program, dialysis, diuretic therapy), then the facility will not be required to complete a new MDS. If the facility does not complete a new MDS, documentation must be entered into the resident’s medical record to support this determination, with appropriate revisions made to the resident’s care plan.