Failure to Implement Interventions and Notify MD/Family After Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to implement interventions and update the care plan after a resident experienced a significant weight loss. The resident had diagnoses including anemia, GERD, a non-pressure chronic ulcer of the left foot, and other malaise, all of which present a risk for weight loss. The resident’s weight decreased from 123.6 pounds on 12/7/25 to 114.4 pounds on 12/22/25, a loss of 9.2 pounds or 7.4% in 15 days, which meets the MDS definition of significant weight loss. The resident’s care plan, dated 10/30/24, already identified risk for weight changes and altered fluid status due to variable meal intake related to physical limitations and cognitive/mood state, and included approaches to monitor for sudden weight loss, weigh per physician orders, and report significant weight changes to the physician and family. Record review showed that the dietician documented a weight warning on 12/29/25 noting the 12/22/25 weight of 114.4 pounds and the percentage changes from prior weights. However, the resident’s care plan was not updated to include any new interventions in response to the significant weight loss, and the record did not show that the physician or family were notified of the weight change as required by the care plan. During interview, the DON stated there should have been a dietitian progress note in December addressing the significant weight loss. In a separate interview, the dietician reported being aware of the weight loss and stated that, after discussing it with the resident who did not want additional interventions and preferred to wait and see if weight increased, no note was written documenting this discussion or decision.
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