Failure to Complete Significant Change Assessment After Notable Weight Loss
Penalty
Summary
The facility failed to conduct a significant change assessment for one resident after a notable decline in health status. The resident, who had diagnoses including dysphagia, muscle wasting and atrophy, heart failure, hypertension, and dementia, experienced a substantial weight loss. Upon admission, the resident weighed 175.4 pounds, but by mid-January, her weight had dropped to 155 pounds, representing a 9.4% loss in one week. Nursing documentation noted poor to fair intake, refusal of some food and drinks, and a recent positive test for Influenza A, which may have contributed to decreased appetite. The resident's diet was adjusted, and nutritional supplements were initiated, but concerns about the accuracy of the weight measurements were documented due to differences in weighing methods. Despite the identification of significant weight loss and ongoing poor intake, the clinical record showed that a Minimum Data Set (MDS) Change of Condition Evaluation was not completed in the month following the weight loss, as required by federal guidelines. The facility's failure to complete this comprehensive assessment within the mandated timeframe after a significant change in the resident's condition constituted the deficiency cited by surveyors.