F0692

G

Severe Undetected Weight Loss Due to Inaccurate Weight Documentation

Holyoke, Colorado Survey Completed on 03-04-2026

Penalty

Fine: $6,368

Summary

The deficiency involves the facility’s failure to ensure accurate weight documentation for four residents with identified nutritional problems, resulting in documented severe weight loss. All residents in the facility, including these four, were weighed weekly on the same day. For each of the four residents, electronic medical record (EMR) entries showed stable or minimally fluctuating weights over several months, followed by a sudden, severe drop in weight over a one‑week period. These drops met criteria for severe weight loss over one week, one month, and three months based on the facility’s own definitions and were later confirmed as accurate when the residents were reweighed on the same scale.

One resident with Alzheimer’s disease, dementia, macular degeneration, and severe cognitive impairment was dependent on staff for eating and had a care plan identifying decreased ability to feed herself and dysphagia risk, with interventions including 1:1 meal assistance, dysphagia diet, fortified foods, supplements, and monitoring weights as ordered. Her EMR showed weights around 100–102 lbs from early fall through mid‑January, then a recorded weight of 87.8 lbs one week later, representing severe loss over multiple time frames. Another resident with congestive heart failure, dementia, brain cysts, traumatic brain compression, and epilepsy, who required moderate assistance with eating and had a care plan for potential nutritional problems and weight monitoring, showed weights in the mid‑teens (approximately 115–119 lbs) over several months, then a sudden drop to 95.2 lbs in one week, also constituting severe weight loss.

A third resident with dysphagia, hemiplegia, chronic kidney disease, severe cognitive impairment, and self‑feeding difficulties had a care plan addressing nutritional risk, need for adaptive equipment, cuing and assistance with meals, snacks, and monitoring for malnutrition and weight changes. Her EMR documented weights around 104–107 lbs from fall through mid‑January, followed by a drop to 89.2 lbs in one week, again meeting severe loss thresholds. The fourth resident, with dysphagia, cerebral infarction, hemiplegia, dementia, chronic kidney disease, and severe cognitive impairment, had a nutrition care plan for significant weight loss, supplements, fortified foods, and monitoring of intake and malnutrition signs. Her weights remained around 128–132 lbs over several months, then abruptly decreased to 111.8 lbs in one week, also classified as severe loss. Interviews with the DON, ADON, RN quality mentor, CNAs, RD, PCP, and NHA established that CNAs obtained weekly weights and provided them to nursing leadership, that previous weights had been verbally relayed and entered into the EMR by the prior DON, and that facility leadership, the RD, and the PCP later concluded there had been inaccurate weight documentation prior to the week when the severe losses were recorded.