F0692

G

Failure to Assess and Address Significant Weight Loss and Poor Intake

Tipton, Indiana Survey Completed on 03-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to adequately assess, monitor, and respond to a resident’s significant weight loss and poor nutritional intake. The resident was admitted with documented problems of weight loss and malnutrition and diagnoses including dementia, major depressive disorder, muscle weakness, muscle wasting and atrophy of both arms, and cognitive communication deficit. Initial records showed a weight of about 181 lbs and a care plan identifying risk of malnutrition with interventions to monitor weights and refer to the dietician for significant weight loss or poor intake. Despite this, subsequent weights showed a decline from 181 lbs in November to 160 lbs in early December, then further decreases over the following months, without consistent documentation that the physician or interdisciplinary team was notified of these changes.

Throughout December, January, February, and March, meal intake records showed the resident frequently refused meals or ate less than half, with numerous entries of 0–50% intake and only some meals at 51–75%. Observations by surveyors showed the resident not eating lunch on one day, with CNA charting indicating refusal and no documented replacement meal or alternatives, and on another day eating less than half of lunch. Nursing notes documented that the resident often did not attempt to feed herself and required cueing, encouragement, and feeding assistance. A December dietician recommendation to add house shakes three times daily for weight stability was not followed by a corresponding order in the medical record for December or January, and a later January dietician note recommending house shakes twice daily was not implemented until mid‑February.

Weight logs and assessments showed progressive weight loss: 160 lbs on 12/8, 149.3 lbs on 1/4, 146.4 lbs on 1/11, 143.9 lbs on 2/15, and 140.7 lbs on 3/23, amounting to approximately a 22% loss over about four months. There was no documentation that the physician was notified of the significant weight loss, and physician progress notes did not reflect assessment or concern regarding the ongoing decline. A quarterly nutritional risk review in February documented no significant weight loss and no referral to the dietician, despite the documented losses, and the dietician’s weekly nutrition-at-risk report for January did not list the resident. During interviews, an LPN stated the resident needed cueing and encouragement to eat but was not being monitored for weight loss, and the DON acknowledged the facility expected some weight loss after hospitalization but was not following the resident for continued weight loss months after discharge and cessation of diuretics. These actions and omissions resulted in unaddressed, significant weight loss for the resident.