Failure to Timely Address Severe Unplanned Weight Loss
Penalty
Summary
The facility failed to address significant weight loss in a timely manner for one resident. Facility policy on Weight Assessment and Intervention required that any weight change of 5% or more since the last assessment be rechecked the next day, and if verified, that nursing immediately notify the dietitian in writing. The policy also defined a 5% weight loss in one month as significant and greater than 5% as severe. The resident had diagnoses including dementia and bilateral heel pressure ulcers. A nutritional assessment by the facility dietitian in early December 2025 indicated the resident was not at risk for unintended weight loss. Weight records showed that the resident weighed 131 pounds on January 7, 2025, and 116.2 pounds on February 4, 2025, an 11.3% (14.8-pound) loss in 30 days, which met the facility’s criteria for severe unplanned weight loss. Review of the clinical record on February 11, 2026, revealed no documentation between February 4 and February 11 that the resident had been reweighed or that the dietitian or physician had been notified of the weight loss, as required by policy. During an interview, the DON stated that the resident was only reweighed on the morning of February 11 after the surveyor questioned the weight loss and confirmed that neither nursing staff nor the dietitian had addressed the weight loss before that time. The DON also confirmed that the resident’s weight on February 11 was 115.6 pounds, reflecting an additional 0.6-pound loss.
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