Inaccurate MDS Assessment of Significant Weight Loss
Penalty
Summary
The facility failed to ensure an accurate comprehensive assessment for one resident when the admission MDS did not reflect a significant weight loss that had occurred prior to and at the time of admission. Record review showed the resident, admitted with malnutrition, gastrointestinal hemorrhage, and dysphagia and requiring nutrition via feeding tube, weighed 213.6 pounds on 12/24/25 and 198.4 pounds on 01/19/26, with an admission assessment weight of 195 pounds on 01/23/26. This represented an 8.66% weight loss between 12/24/25 and 01/23/26. However, the admission MDS documented that the resident had not experienced a weight loss of 5% or more in the last month. During interview, an LPN reported the resident had been placed on five daily bolus feedings of Jevity 1.5 for a few days, and the MDS coordinator, after reviewing the weight summary, acknowledged that the admission assessment should have indicated a weight loss of over 5% in one month.
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