F0692

G

Failure to Identify and Intervene for Severe Weight Loss in Multiple Residents

Herrin, Illinois Survey Completed on 01-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to identify and respond to severe weight loss in three residents and to implement needed nutritional interventions despite clear evidence of declining weights and poor intake. For one resident with multiple chronic conditions including CHF, dysphagia, COPD, diabetes, dementia, and depression, daily weights showed a progressive and severe weight loss over 1, 3, and 6 months, with electronic alerts indicating significant losses. January intake records documented multiple meals with only 0–25% or 26–50% consumed and several meals with no documentation. The care plan identified risk for nutrition and hydration issues and directed staff to monitor, record, and report significant weight loss, but no new interventions were implemented in response to the documented severe weight loss, and there was no evidence of RD follow-up after an RD note from several months earlier that had been based on prior weight gain and higher intake levels.

A second resident, admitted with diagnoses including diabetes, fracture, muscle wasting, and dysphagia, experienced a documented 6.9% weight loss in 30 days and a 10.2% loss since admission, with a BMI of 17.1 indicating underweight. The weight record contained clearly inaccurate high weights that were not rechecked, and the DON later confirmed these entries were wrong and should have prompted reweighs. The RD’s December assessment for this resident relied on one of these inaccurate weights and concluded the resident was consuming 51–100% of meals and should continue the current diet, with no additional interventions for weight loss. The resident’s care plan addressed only ADL performance and supervision with eating and did not include any focus area or interventions related to nutrition or weight loss, despite the documented severe weight loss and the resident’s report of poor intake due to disliking the food and receiving cold meals.

A third resident with Alzheimer’s disease, dementia, muscle wasting, and other chronic conditions had documented significant weight loss over 30 days and 6 months, meeting the facility’s own definition of severe weight loss. The care plan identified risk for nutrition and hydration issues and included monitoring and reporting of significant weight loss, as well as provision of a regular diet with supplements such as super cereal, whole milk, health shakes three times daily, and ice cream at lunch. Weight records showed a drop from the 130-pound range to just over 106 pounds, and intake sheets for January documented frequent 0–25% and 26–50% meal intakes, with multiple days lacking documentation. RD notes over several months acknowledged 7.5% and then 10.5% weight loss and recommended continuing the regular diet with house supplements, encouraging intake, and monitoring weights and intakes, but the last new intervention (ice cream at lunch) had been implemented months earlier, and no new interventions were put in place in response to the most recent severe weight loss.

Across these three residents, the DON stated that she alone reviews monthly weights, that there are no formal IDT meetings to review weights, and that the RD selects which residents to see based on monthly weights without being provided a list of new admissions, residents with weight loss, or residents with wounds. The DON acknowledged that no interventions were implemented for one resident’s severe weight loss and that the RD had not seen that resident since mid-year despite ongoing weight decline. The NP reported she had not received recent notifications about residents’ weight losses and that prior notifications had related to weight gain, and she found no RD or nursing notifications or recommendations in the chart regarding the recent weight losses. CNAs reported that they perform weights and record meal intakes, that snacks are generally not offered between meals and are inconsistently available at bedtime, and that residents sometimes do not receive snacks because the kitchen runs out. The facility’s written policy on weight assessment and intervention requires nursing and the RD to cooperate to prevent, monitor, and intervene for significant weight changes and to focus interventions on food and snacks first, but the documented practices and lack of timely interventions for these three residents’ severe weight loss did not follow those policy expectations.