Failure to Implement Care Plan for Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to implement a comprehensive, resident-centered care plan intervention to prevent nutritional and hydration alterations for one resident. The resident had multiple medical diagnoses, including Parkinson’s disease, CHF, COPD, GERD, and a BMI of 35.9 (class II obesity), and was identified in a care plan dated March 9, 2026, as being at nutritional risk related to these conditions. The care plan interventions included monitoring, recording, and reporting to the physician signs and symptoms of malnutrition, specifically including significant weight loss of 3 lbs in a week, greater than 5% in one month, greater than 7.5% in three months, and greater than 10% in six months. Review of the resident’s 30‑day weights showed an admission weight of 171.4 lbs on March 5, 2026, 172 lbs on March 9, 2026, and 165 lbs on March 16, 2026, indicating a 7‑lb loss in 7 days. Despite this, there was no documentation in the progress notes that the physician was notified of the weight loss, as required by the care plan intervention. During an interview, the dietician stated that dietary staff only assess residents who trigger for a 5% or greater weight loss or if requested by nursing, and that the 7‑lb loss represented a 4.07% decrease, which did not meet the 5% threshold used by dietary. The dietician confirmed creating the interventions but was not aware of the specific intervention requiring physician notification for a 3‑lb weekly weight loss, acknowledged the intervention was generic and not resident‑centered, and confirmed the physician was not notified of the weight loss.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.