F0692

D

Failure to Monitor and Intervene for Significant Weight Loss in a Malnourished Resident

Springfield, Pennsylvania Survey Completed on 03-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to monitor and intervene appropriately for significant weight loss in a resident with severe protein-calorie malnutrition. Facility policy required residents to be weighed on admission and at intervals set by the interdisciplinary team, with any weight change of 5% or more to be rechecked the next day and, if confirmed, immediately reported to the dietitian. The policy also required evaluation of undesirable weight changes by the treatment team, including review of target weight range, nutrient needs versus intake, and medical conditions or medications contributing to weight loss. Despite these requirements, the facility did not consistently follow its own policy for one resident.

The resident was admitted with a diagnosis of unspecified severe protein-calorie malnutrition and an initial malnutrition risk assessment documented severe fat and muscle loss and risk for malnutrition related to acute and chronic medical conditions. A subsequent nutritional risk assessment showed a recent weight of 126.6 lbs and identified moderate decreased food intake over the prior three months, low BMI for age, impaired skin integrity with stage 2 and 3 pressure injuries, and an altered texture diet. The care plan documented a nutritional problem related to multiple chronic conditions, severe PCM, and significant recent weight loss, with goals to maintain weight within 5% of current body weight and consume at least 75% of three meals daily. Interventions included monitoring and recording intake, obtaining weights at ordered intervals, and reporting significant weight loss and signs of malnutrition to the practitioner.

Weight records showed the resident’s weight decreased from 127 lbs to 110 lbs within a short period, with reweighs on the same and following day showing 113.8 lbs and 107 lbs, respectively, resulting in a documented unintentional and unfavorable 13.4% weight loss in less than one month. A dietitian’s progress note on that date attributed the weight loss to variable oral intake with refusal of some meals and increased nutrient demands, and recommended increased supplements, fortified foods, additional protein, vitamins, and weekly weight monitoring. However, there was no documented evidence that weekly weights were obtained after that date until discharge, nor that the dietitian conducted further evaluation or monitoring of the resident’s weight, food, or caloric intake. Food intake records for multiple days in the same month showed repeated zero or low intake at meals, with frequent refusals, and interviews with the administrator and the full-time dietitian confirmed the absence of further weights and documented interventions to address the resident’s poor appetite.