Failure to Complete SCSA After Significant Unplanned Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to complete a Significant Change in Status Assessment (SCSA) in the MDS within 14 days after a resident experienced a significant, unplanned weight loss. The resident had a documented weight decrease from 117.4 lbs to 110.6 lbs over a 30-day period, a 5.8% loss, which met both facility and RAI criteria for significant weight loss requiring comprehensive reassessment and an SCSA. Despite this documented change, there was no evidence that an SCSA was initiated or completed within the required timeframe. The resident had multiple complex medical conditions, including neurocognitive disorder with Lewy bodies, Parkinson’s disease, adult failure to thrive, dysphagia, anorexia, and cognitive communication deficit. The admission and subsequent quarterly MDS assessments documented severely impaired cognitive skills, total dependence for ADLs and mobility, frequent bladder and bowel incontinence, unhealed pressure ulcers (including Stage 3 and Stage 4 ulcers), and weight loss of 5% or more in one month or 10% in six months while not on a physician-prescribed weight-loss regimen. The resident was on a mechanically altered diet, later changed to puree, and was receiving nutritional supplements and an antidepressant. Staff interviews confirmed that the resident had poor oral intake, was non-verbal, required feeding assistance and encouragement to eat, and had multiple pressure ulcers and impaired mobility. The wound nurse and wound NP described the resident as frail, thin, underweight, and at risk for impaired wound healing, and the dietitian stated that unplanned weight loss of 5% or more in 30 days is significant and requires intervention. The RN unit manager stated that significant weight loss should prompt notification of the dietitian and physician and documentation in progress notes but did not recall this resident’s significant weight loss. The DON stated that monitoring weight is the responsibility of all disciplines and deferred to the dietitian regarding whether a 5% weight loss constituted a significant change, yet no SCSA was completed despite the documented significant, unplanned weight loss and associated clinical indicators.
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