F0580

D

Failure to Notify Physician and Family of Significant Weight Loss and Weight Refusals

South Bend, Indiana Survey Completed on 01-16-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to notify a resident’s physician and responsible party of repeated refusals to be weighed and of significant, documented weight loss. The resident, who had Alzheimer’s disease, neurocognitive disorder with behavioral disturbance, delusional disorder, insomnia, and muscle weakness, was admitted with an initial weight of 178 lbs. A quarterly MDS dated 10/22/25 showed the resident weighed 170 lbs, had severe cognitive impairment, exhibited negative behaviors, wandered daily, and was receiving antipsychotic and antianxiety medications. A discharge MDS dated 11/26/25 documented inattention, disorganized thinking, multiple behavioral symptoms including rejection of care, and a weight of 156 lbs.

Physician’s orders included a regular diet and monthly weights starting 7/23/25. The care plan identified behavioral symptoms including refusal of vital signs, with interventions to reapproach the resident and notify the physician and psychiatric services for increased behavioral symptoms. Another care plan, dated 10/19/25, identified potential nutritional risk related to diagnoses, a weight refusal in October, and significant weight loss of 14.7% over the prior 90 days, with interventions to document food and fluid intake and notify the physician of abnormal findings. Weight records showed a decline from 178 lbs in late July to 170 lbs in early September, then to 152 lbs on 11/6/25 and 156 lbs on 11/11/25, reflecting approximately 14% loss in less than five months; an ER record on 11/26/25 documented a weight of 146 lbs, over 17% loss in five months.

Meal intake documentation between 10/1/25 and 11/26/25 showed multiple missing entries for breakfasts, lunches, and suppers, and several recorded intakes of 0–25% at various meals. A nutrition review on 8/1/25 noted good intake (76–100% of most meals) and made no dietary recommendations. A dietary note on 11/21/25 recorded that no weights had been entered for 30 days, that the resident had lost 26 lbs in 90 days (14.6% loss from 170 to 152 lbs), and that the resident’s BMI was 29.5, with no recommendations made and a plan to continue monitoring. During interview, the DON confirmed there was no documentation that the physician or responsible party had been notified of the significant weight loss or weight refusals, and the family member reported they were never informed of the resident’s significant weight loss. Facility policies on weight monitoring and change in condition required notification of the physician and family/guardian for verified significant weight changes and abnormal weights, and documentation of such notifications, which did not occur in this case.