F0692

D

Failure to Monitor Nutritional Status and Weight Loss After Interventions

Omaha, Nebraska Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to adequately monitor and follow up on a resident’s nutritional status and weight loss after nutritional interventions were implemented. Facility policy required that residents with weight loss be monitored with weekly weights and that interventions be identified, implemented, monitored, and modified as appropriate. The resident, who had Alzheimer’s disease with late onset and stage 3 chronic kidney disease, was care planned for significant weight loss and was receiving a mechanical soft diet, med pass supplement, and snacks as requested. Dietary notes documented progressive weight loss, including a 3.5% loss in 30 days and an 8.9% loss in 90 days, with plans for the RD to monitor oral intake, diet status, weight trends, and skin integrity.

Despite these interventions and plans, the facility did not obtain weekly weights as required for a resident with weight loss, as confirmed by the RD. The weight and vital summary showed a weight of 134.8 lbs. on one date and then no further recorded weight until a later date when the resident’s weight had dropped to 121 lbs., reflecting a 10.2% loss over that period, followed by another recorded weight of 114 lbs. one week later, a 5.79% loss in that week. Additionally, a prealbumin lab was ordered due to unintended weight loss, but no result was found in the record for that order, and the regional nurse consultant confirmed that no result could be located. A later prealbumin result showed a level of 14, which could indicate malnutrition. These gaps in weight monitoring and lack of documented follow-up on the initial prealbumin order occurred despite the resident being identified with significant weight loss and having nutritional interventions in place.