F0692

D

Failure to Timely Address Significant Weight Loss and Implement RD Recommendations

Tunkhannock, Pennsylvania Survey Completed on 01-30-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to timely identify and respond to significant weight loss for one resident, contrary to its own Weight Policy. The policy required admission/readmission weights, weekly weights for three weeks, then monthly weights unless otherwise ordered, verification of any weight with significant variance, tracking of significant weight losses by the RD, and notification of the MD and responsible party of significant weight changes. Resident 5 had a care plan initiated for nutritional problems related to advanced age, mechanically altered diet texture, and mild protein store depletion, with goals to maintain weight and avoid significant weight changes, and interventions including weekly weights and RD evaluation with recommendations as needed. A physician order dated mid-December directed weekly weights.

Weight records for Resident 5 showed weights of approximately 120.5–121.5 pounds over three consecutive weekly measurements, followed by a documented weight of 105 pounds on January 11, 2026, reflecting a loss of 16.5 pounds, or about 13.5% of body weight in one week. The clinical record did not contain documentation that this large change was rechecked promptly to verify accuracy, despite the facility’s policy that a nurse should verify weights showing significant variance. A remote RD note on January 15, 2026, identified the significant weight loss and recommended a reweight, but the resident was not reweighed until January 16, 2026, when the weight was recorded as 106 pounds, still reflecting a significant loss. A subsequent RD note documented a 12.4% weight loss in less than 30 days and 8.2% in three months, and recommended fortified foods with all meals and a 4 oz nutritional shake with lunch and dinner.

Although the RD documented that the resident was to receive 4 oz nutritional shakes with lunch and dinner and that the resident was consuming about 75% of meals on a mechanical soft diet with thin liquids, the clinical record did not show that the recommended nutritional interventions, including the shakes, were implemented in a timely manner after the significant weight loss was identified. The record also lacked documentation that the attending MD and the resident’s responsible party were notified of the significant weight loss. Subsequent weights showed a further decline to 104 pounds. During an interview, the DON confirmed that there was no additional documentation to demonstrate timely MD and responsible party notification, timely implementation of nutritional interventions, or timely reweights, corroborating the identified deficiency.