F0580

D

Failure to Notify Physician and Family of Significant Weight Loss in Two Residents

Bement, Illinois Survey Completed on 01-21-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to notify physicians, the dietitian, and family members of significant weight loss and decreased nutritional intake for two residents, contrary to its own policies on change in condition and impaired nutrition/unplanned weight loss. The facility’s policy required staff to monitor and document residents’ weights in a way that allowed month-to-month comparison, identify recent or rapid weight loss, and notify the physician and family of significant weight changes or persistent declines in appetite or intake. The policy also required the physician and staff to review possible causes of weight loss and monitor nutritional status and response to interventions.

For one resident (R1), admitted with diabetes mellitus due to underlying condition with diabetic neuropathy and other lack of coordination, weight records showed a decline from 175.2 lbs at admission to 161.1 lbs at discharge over 22 days, a total loss of 14.1 lbs or 8%. During the stay, the resident was served 61 meals; documentation of intake was missing for 6 meals, and of the 55 meals with documentation, 29 meals showed less than 50% consumption and 15 meals showed less than 25% consumption. The LPN who documented in the record stated they did not recall notifying the family or physician of the resident’s decline and confirmed they did not inform them of the weight loss. The NP, RD, and primary care physician each confirmed they had not been notified of the resident’s weight loss, and the family member confirmed they were not informed of the weight loss or lack of food consumption. The DON confirmed the resident had a significant weight loss and that the family, physician, and RD had not been notified.

For another resident (R8), admitted with multiple acute conditions including mechanical fall with right lower extremity fractures, severe pain, acute hypotension/shock versus anemia, acute anemia, suspected GI bleed ruled out, acute kidney injury on chronic kidney disease, and atrial fibrillation, serial weights showed a decline from 201.8 lbs near admission to 161.1 lbs over 44 days, a total loss of 36.8 lbs or 19%. Despite this significant weight loss, the NP and the resident’s physician each confirmed they had not been informed of any weight loss. The resident’s family member reported noticing that the resident was losing weight but was unaware of the extent of the loss and stated they had not been notified by staff. The DON confirmed that this resident also had significant weight loss and that the family and physician had not been notified, demonstrating a failure to follow facility policy for physician and family notification of significant changes in condition related to weight and nutrition.