F0692

D

Failure to Timely Re-Weigh and Address Significant Resident Weight Loss

Spring House, Pennsylvania Survey Completed on 01-23-2026

Penalty

No penalty information released

Summary

The facility failed to address a resident’s significant weight loss in a timely manner, contrary to its policy on Weight Assessment and Intervention. The policy, revised in March 2022, required that any weight change of 5% or more since the last weight assessment be rechecked the next day for confirmation. The resident, who had diagnoses including hypertension, cerebral infarction (stroke), and chronic kidney disease, had a documented weight of 138 pounds on a monthly weight dated May 3, 2025. A subsequent monthly weight dated June 6, 2025 showed a weight of 129 pounds, reflecting a 9‑pound loss and a significant 6.5% decrease. The clinical record from May 2025 through June 2025 did not contain evidence that a re‑weight was obtained to verify this significant weight loss.

A dietician note dated June 11, 2025 documented that weight loss was noted and that a re‑weight had been requested, and a subsequent dietician note dated June 25, 2025 indicated the dietician was still awaiting the re‑weight and recommended an increase in house shakes until an accurate weight was determined. Despite these documented requests, there was no documentation in the clinical record that a re‑weight was completed in a timely manner to verify the weight loss and to ensure that any needed services and interventions were implemented. During an interview on January 23, 2026, the dietician confirmed the resident’s 6.5% significant weight loss, acknowledged the prior notes requesting a re‑weight, and confirmed that the next recorded weight after the June 6, 2025 measurement did not occur until July 1, 2025, 25 days after the significant weight loss was first recorded. The dietician also reported that the facility did not have a standard time frame for obtaining re‑weights for residents with possible significant weight loss.