Failure to Obtain Admission Weight Led to Inaccurate Baseline and Triggered Weight Loss Variance
Penalty
Summary
The deficiency involves the facility’s failure to obtain an admission weight in accordance with professional standards of practice for one resident. The resident was re-admitted with multiple diagnoses including sepsis, osteoarthritis of the hip and knee, cognitive communication deficit, hypokalemia, hypothyroidism, hyperlipidemia, thrombocytopenia, vitamin D deficiency, GERD, hypertension, and a disorder of phosphorus metabolism. The resident’s MDS showed intact cognition, supervision or touch assistance needed with eating, and moderate assistance needed with toileting and transfers. A physician order dated 1/27/2026 requested an RD consultation to evaluate and treat as needed. However, the dietary profile dated 2/3/2026 showed no weights recorded, and there was no documented weight at the time of admission. Because an admission weight was not obtained, the RD used the most recent GACH weight of 110 lbs from 1/24/2026 as the baseline. A subsequent physician order dated 2/13/2026 called for weekly weights for four weeks. An IDT note dated 2/20/2026 documented that the MDS triggered a significant weight change, comparing the 110 lb hospital weight to later weights and identifying an approximate 19–19.2 lb loss, or 17.3%–17.5% change, which was described as clinically significant and placing the resident at risk for malnutrition, functional decline, dehydration, and increased morbidity. The RD’s care plan revision on 2/11/2026 listed weights of 110 lbs on 1/24/2026, 89.4 lbs on 2/4/2026, and 90.5 lbs on 2/9/2026, and documented a 20.6 lb/18.7% one-month loss. In interview, the RD stated there was no weight documented at admission, so the last hospital weight was used as the baseline, and acknowledged that ideally the RNA would obtain an admission weight and that the use of the hospital weight had triggered a weight loss variance.
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