F0692

D

Failure to Identify and Address Significant Weight Loss

Dyer, Indiana Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to identify and address significant weight loss for a resident with multiple comorbidities, including Parkinson’s disease, diabetes mellitus, and morbid obesity. A Significant Change MDS dated 12/14/25 documented the resident’s weight at 294 pounds with no significant weight loss or gain and noted that she was on a therapeutic diet and hypoglycemic medication. The care plan, revised on 12/23/25, identified a nutritional problem related to a BMI over 40, therapeutic diet, and prior weight gain, with a goal to maintain adequate nutritional status and stable weight. Interventions included monitoring meal intake, obtaining a nutritional consult on admission, quarterly and as needed, obtaining weekly weights if unplanned weight loss was identified, and providing meals per physician orders.

Weight records showed the resident’s weight fluctuated from 296.6 pounds in early July 2025 to 293.5 pounds in November 2025. The resident was hospitalized for shortness of breath on 11/29/25 and readmitted on 12/3/25. A physician’s order dated 12/6/25 required weekly weights for four weeks, but the MAR for 12/2025 showed only one documented weight on 12/12/25 at 293.5 pounds, with no further weekly weights recorded until 2/3/26. An RD assessment on 12/15/25 referenced a weight of 293.5 pounds, noted dietary intakes of 75–100%, and estimated calorie needs of 1850–2200, with goals to maintain adequate nutritional status and stable weight. The resident expressed a desire to lose weight, but there were no care plan interventions or documentation that staff, the physician, or the responsible party were notified of this request.

Subsequent information revealed undocumented weights and unrecognized significant weight loss. A weight on 2/3/26 was 259.3 pounds, representing an 11.6% loss from the 12/12/25 documented weight and a 14.5% loss over six months, while intake records for 12/2025 through 2/2026 showed average meal intakes of 76–100%. The RD’s 2/5/26 note identified a 10% loss in 180 days and questioned weight accuracy, requesting a re-weight. During interview, the Corporate RN Consultant reported that weights of 272.1 pounds on 12/8/25 and 264.6 pounds on 1/5/26 had been obtained but not documented in the record, resulting in staff and the RD being unaware of the ongoing weight loss, and the physician, NP, RD, and responsible party not being notified. The Restorative Aide stated she weighed residents, wrote weights on paper, and gave them to the Unit Manager for entry, and she was unaware the resident required weekly weights. The facility’s weight policy required admission weights, weekly weights for four weeks, and documentation of weights and any concerns in the record, but these requirements were not followed for this resident, leading to the failure to identify and address her significant weight loss.