F0692

G

Failure to Monitor Weights and Implement Ordered Nutritional Interventions

Hanover, Pennsylvania Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to monitor and respond to residents’ weight changes in accordance with its own policies and clinical standards of practice. The facility’s Weight Assessment and Intervention policy required weights on admission and then weekly for four weeks, with any weight change of 5 lb or more to be rechecked and, if verified, reported to the physician and dietitian. For one resident with dysphagia who was hospitalized and then readmitted, the weight increased from 130.5 lb to 143 lb between early November and the December readmission, and then decreased to 128 lb by early January, representing changes greater than 5 lb on both occasions. The clinical record showed that no reweights were obtained after these significant changes, and both the RD and the NHA acknowledged that a reweight should have been obtained but was not.

Another resident, admitted with diagnoses including hypertension and a history of falls, was identified on admission as being at risk for weight loss due to the healing process from a femur fracture. This resident’s weight declined from 121.9 lb at admission to 96.6 lb over less than three months, with documented significant weight losses noted by the RD, including an 11 lb (9.1%) loss and subsequent 10% and 9.3% losses over 30-day periods. The RD recommended fortified foods, liquid protein, and weekly weights for four weeks, and obtained a physician’s order for a regular diet with fortified foods. However, weekly weights ordered in November and December were not consistently obtained, and the fortified foods ordered by the physician were not added to the resident’s meal ticket or provided until mid-January, despite multiple WEIGHT WARNING notes and acknowledgment by the RD and NHA that the fortified foods should have been implemented earlier. The resident’s nutritional assessments were based on the assumption that fortified foods were being consumed, although they were not.

A third resident, admitted with dysphagia and dementia, also did not receive weight monitoring as required by facility policy. The December physician orders for this resident did not include weekly weights for four weeks following admission, and the weight history showed only two weights, one in early December and one in early January, with no weekly weights documented in between. The RD stated that the admission weight was obtained but nursing failed to enter the physician order for weekly weights, resulting in the absence of weekly weights for four weeks after admission. The NHA confirmed that weekly weights for four weeks after admission were not obtained for this resident, contrary to facility policy.