Failure to Obtain Monthly Weight Resulting in Unrecognized Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to obtain a required monthly weight for a cognitively impaired resident with multiple medical conditions, resulting in an unrecognized, significant unplanned weight loss. The resident had diagnoses including unspecified systolic congestive heart failure, muscle weakness, and unspecified intestinal obstruction, and required a wheelchair for mobility, supervision or touching assistance with eating, and substantial assistance with ADLs. The care plan identified self-care performance deficits related to limited mobility, anemia, cognitive communication impairment, polyneuropathy, hypotension, and congestive heart failure, and included interventions such as setting up meal trays, encouraging self-feeding, offering assistance or finger foods, opening and cutting food, and notifying the nurse if the resident was not eating. The care plan also identified risk for nutrition and hydration deficits related to a recent small bowel resection and planned significant weight gain, with interventions including weighing as ordered, providing supplements as ordered, and monitoring for signs and symptoms of malnutrition and significant weight loss. Despite these identified risks and interventions, the medical record showed that the resident’s weight was recorded as 142 lbs in early December, but no weight was obtained in January, contrary to the facility’s weight monitoring policy that required monthly weights for all residents and weekly weights for residents with weight loss. Subsequent weights in early February showed a drop to 123.6 lbs and then 121.4 lbs. A dietician progress note documented that the resident reported decreased appetite, had a moderate decrease in food intake over the prior three months, was receiving Ensure daily and was receptive to increasing it to twice a day, and had a mini nutrition score indicating malnutrition, with a notation that no January weight was recorded. In an interview, the diet technician confirmed the resident had a significant weight loss, should have been weighed weekly, and was not weighed in January, stating the missed weight must have been overlooked during daily interdisciplinary team meetings and acknowledging that the resident frequently refused to eat and that staff should have notified nursing or the diet technician if the resident was refusing meals.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.