F0692

D

Failure to Monitor and Intervene for Significant Weight Loss

Lubbock, Texas Survey Completed on 02-04-2026

Penalty

No penalty information released

Summary

The facility failed to maintain acceptable nutritional status for a resident who experienced a significant, unplanned weight loss of 16.8 pounds, representing a 10% loss of body weight between early December and mid-January. The resident was an older adult female with diagnoses including a lumbar compression fracture, Type 2 diabetes mellitus, osteoporosis, and a cognitive communication deficit, but with intact cognition per an admission BIMS score of 15. Her admission MDS documented an admission weight of 158 pounds, no poor appetite, independent eating with setup assistance, and an LCS regular diet with thin liquids. The comprehensive care plan, initiated shortly after admission and later revised, identified a nutritional problem related to diabetes and set a goal for the resident to maintain weight within 3% of 145.8 pounds, with interventions to provide the ordered diet, monitor and record intake each meal, and have the RD evaluate and recommend diet changes as needed.

Weight records showed the resident’s weight decreased from 158 pounds on admission to 145.8 pounds by early January and then to 141.2 pounds by mid-January, meeting the facility policy’s threshold for significant weight loss. The facility’s policy required residents to be weighed on admission, the next day, and weekly for two weeks, then monthly if no concerns, and to recheck any 5% or greater weight change the next day, with immediate written notification to the dietitian if confirmed. The DON later stated that newly admitted residents were usually weighed upon admission, weekly for four weeks, then monthly, and that residents should also be weighed upon readmission from the hospital. However, the resident was not weighed weekly upon admission, was not weighed upon readmission from a hospital stay in December, and the DON acknowledged being unsure why these weights were missed. The DON also stated he was not aware of the extent of the resident’s weight change and that the significant change noted on the early January weight was overlooked.

The dietitian’s documentation and statements further showed that required nutritional follow-up was not completed or recorded in response to the resident’s weight changes. The dietitian reported seeing the resident shortly after admission and again in early January, noting some weight loss but believing the admission weight might be inaccurate based on the resident’s reported usual weight of 145–150 pounds. No recommendations were made at that time, and the dietitian did not enter a note in the electronic health record for the early January visit. The resident reported losing over sixteen pounds since admission, attributed her weight loss to limiting foods that might raise her blood sugar, described herself as a picky eater who did not care for some facility foods, and stated she brought her own protein shakes and was not offered liquid supplements by the facility. She also reported being weighed only once or twice a month and not recalling a dietitian visit since admission. Meal intake records showed variable intake, with multiple days where she consumed 50% or less of meals, despite the care plan goal of consuming at least 75% of three meals daily. These actions and inactions in monitoring weights, confirming significant changes, notifying the dietitian, and implementing timely nutritional interventions led to the resident’s significant weight loss.

Staff interviews corroborated that the facility’s processes for weight monitoring and nutritional follow-up were not consistently implemented for this resident. The CNA responsible for passing lunch trays stated the resident usually consumed 75–100% of meals and was receiving sandwiches as snacks, and that she would notify the kitchen and offer alternatives if residents complained about food. The LVN stated that CNAs on day shift were responsible for obtaining monthly weights and that she believed new residents were weighed on admission and monthly, with the DON responsible for notifying the physician of changes. The DON stated that a transportation aide obtained weights and turned them in for entry into the electronic record, and he was unsure why the resident was not weighed weekly or upon readmission. The administrator stated he was not aware of the resident’s significant weight loss until a care plan meeting and that he and the DON were ultimately responsible for ensuring weights were monitored and significant changes were addressed. The facility’s written policy on weight assessment and intervention, including thresholds and required actions for significant weight loss, contrasted with the actual practice documented for this resident, resulting in a failure to implement appropriate monitoring and interventions to prevent or address her significant weight loss.