Failure to Address Significant Unplanned Weight Loss
Penalty
Summary
A deficiency was identified when a resident experienced a significant, unplanned weight loss, dropping from 190 pounds in July to 168 pounds in August, representing an 11.5% loss in one month. This exceeded the CMS guideline for significant weight loss, yet there was no documented evidence that the dietician implemented new nutritional interventions to address the decline prior to the survey. The facility's policy required specific actions when significant weight loss is detected, such as weekly and monthly weights, review of food intake, initiation of a 3-day caloric count, and identification of possible causes, but these steps were not documented as completed. The resident, who had diagnoses including dementia, anxiety disorder, and type 2 diabetes, required supervision or assistance with eating and other activities of daily living. Despite a care plan goal to prevent significant weight changes and ensure adequate meal and supplement intake, records showed the resident was not consuming full meals and often only ate part of a sandwich when offered as an alternative. Staff interviews confirmed that the resident was not eating the hot meals provided and that this was known among staff, but there was no evidence of escalation or intervention by the dietician or nursing team. Documentation from the dietician and changes to the plan of care were absent during the period of weight loss. The DON stated that a calorie count was not initiated because meal intake records indicated the resident was eating 50% of meals, though direct observation and staff interviews contradicted this. The medical director indicated that, in cases of significant weight loss, a calorie count and further investigation would typically be pursued, but there was no evidence these steps were taken for this resident.