F0657

E

Failure to Revise Care Plan for Ongoing Significant Weight Loss

Monrovia, California Survey Completed on 03-03-2026

Penalty

No penalty information released

Summary

The facility failed to timely revise and update the care plan for a resident who experienced significant unplanned weight loss. The resident was admitted with hemiplegia and hemiparesis following a stroke affecting the left non-dominant side, as well as diabetes mellitus, and was cognitively intact but dependent on staff for ADLs. Weight records showed a decline from 225 lbs at admission to 178 lbs over approximately five months, including a 24-lb loss in one month and a subsequent 19-lb loss over a later two‑month period. A care plan for unplanned/unexpected weight loss of 24 lbs in one month was initiated and revised in October, with interventions to contact the physician and dietician if weight decline persisted and to monitor and evaluate any weight loss and determine percentage lost per facility protocol.

Despite continued weight loss documented in the Weights and Vitals Summary, the care plan was not updated when the resident lost an additional 19 lbs between early November and early January, and there was no care plan indicating that the resident was intended to lose a total of 47 lbs in five months. The unplanned/unexpected weight loss care plan was not updated again until late January. Interviews revealed that the resident was very alert, initially on a puree diet with low intake, later on a regular diet, and frequently ordered food from outside the facility because the resident did not like facility food. The registered dietician reported that the resident had a personal goal weight of 170 lbs, had lost 19 lbs in three months before the dietician began working at the facility, then 1 lb in a month afterward, and was non‑compliant with the prescribed diet and ordering a lot of outside food. These findings showed that the care plan interventions were not revised in a timely manner in response to ongoing weight loss.