Failure to Implement RD-Recommended Weekly Weights for Resident With Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to follow the Registered Dietician’s (RD) recommendations for weekly weights for a resident with documented significant weight loss. The resident’s care plan dated 12/22/2025 notes a significant 6.1% weight loss in one month, with a weight of 153.3 lbs, and further documents that the resident eats about 50% or less of meals and gets up from the table before completing meals. The care plan also notes a 10.7% weight loss over three of six months between December 2024 and March 2025. In response to this weight loss, the RD documented on 1/24/2025 that the resident had lost 10 lbs (6.1%) between 12/16/2024 (163 lbs) and 1/10/2025 (153 lbs) and recommended weekly weights. However, the January weight summary shows only one weight obtained on 1/10/2025. Despite repeated RD notes reinforcing the need for weekly weights due to ongoing weight loss, the facility did not implement these recommendations. On 2/26/2025, the RD documented a weight of 145.8 lbs, a 5% loss from 1/10/2025, and again recommended continuing weekly weights, but the February summary shows only one weight on 2/19/2025. On 3/14/2025, the RD recommended continuing weekly weights for four weeks, yet the March summary shows only two weights (3/13/2025 and 3/21/2025). On 4/3/2025, the RD again recommended weekly weights for four weeks, but the April summary shows only one weight on 4/5/2025. During interviews, two CNAs stated they believed the resident was only on monthly weights and were not aware of any weekly weight order, and an RN confirmed weekly weights were not performed because she was not aware they were needed. The RD stated she documents her recommendations in dietary notes and expects nursing staff to review these notes and obtain orders from the physician, confirming that weekly weights were recommended due to the resident’s significant weight loss.
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