Failure to Identify and Assess Significant Weight Loss
Penalty
Summary
Facility staff failed to accurately identify and assess a significant change in a resident's physical condition using the Resident Assessment Instrument (RAI) process. Specifically, a resident with multiple diagnoses, including osteoarthritis, Alzheimer's disease, hypertension, type 2 diabetes mellitus, atrial fibrillation, chronic kidney disease stage 3, and a history of digestive system surgery, experienced a 6.1% weight loss over thirty days. Despite this, the comprehensive Minimum Data Set (MDS) assessment did not reflect the significant weight loss, as Section K0300 was coded to indicate no weight loss of 5% or more in the last month. A nurse's progress note documented the significant weight loss, but this information was not incorporated into the MDS assessment. During a staff interview, an LPN acknowledged that the MDS should have been coded as a significant change assessment due to the unplanned weight loss and that the weight loss should have been recorded. The deficiency was identified through clinical record review, staff interview, and facility document review, and was discussed with facility leadership prior to survey exit.