F0692

D

Failure to Timely Implement Nutritional Interventions and Notify MD/RP After Significant Weight Loss

Tunkhannock, Pennsylvania Survey Completed on 03-24-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to timely identify and respond to significant weight loss and nutritional changes for one resident, in violation of its own weight policy. The facility’s policy required obtaining admission and follow-up weights, tracking significant weight losses of 5% in one month, 7.5% in three months, or 10% in six months, and ensuring that the MD and responsible party were notified of significant changes. For this resident, weights documented were 124 lbs on January 4, 120 lbs on February 1, 117 lbs on March 3, 118 lbs on March 15, and 114.5 lbs on March 22. The March 22 weight reflected approximately a 3% loss in one week and a 7.5% loss since January 4, but the record did not show that a reweight was obtained to verify this significant change as required when there was a notable variance.

The resident had dementia, major depressive disorder, severe cognitive impairment (BIMS score of 1), and an existing care plan for nutritional problems related to advanced age, mechanically altered diet, and thickened liquids. The care plan set a goal to maintain weight within 3% of 124 lbs and to consume 75% of at least two meals daily, with interventions including fortified foods, a 4 oz nutritional shake with meals, a 4 oz frozen nutritional supplement daily, obtaining weights as ordered, and RD evaluation with recommendations. The remote RD responded to a weight alert on February 21 for the February 1 weight, noting an approximate 3% (4 lb) loss and recommending a 4 oz nutritional shake with meals three times daily. However, the corresponding physician order for the nutritional shake with meals was not entered until March 4, eleven days after the RD’s recommendation.

A subsequent RD weight change note on March 9, in response to the March 3 weight, documented a 10% (14 lb) loss over 180 days and recommended a 4 oz frozen nutritional supplement with dinner and weekly weights. The physician order for weekly weights was entered on March 9, but the order for the 4 oz frozen nutritional supplement with dinner was not entered until March 17, eight days after the RD’s recommendation. The clinical record did not contain evidence that the recommended nutritional interventions (4 oz shakes with meals and 4 oz frozen supplement with dinner) were implemented in a timely manner following identification of weight loss. Additionally, the record lacked documentation that the attending physician and the resident’s responsible party were notified of the significant weight loss identified on March 22. During interview, the DON confirmed there was no additional documentation to show timely notification or timely implementation of the recommended interventions.