F0692

D

Failure to Timely Address Significant Resident Weight Loss

Fullerton, California Survey Completed on 03-26-2026

Penalty

No penalty information released

Summary

The facility failed to ensure timely nutritional intervention for a resident who experienced significant, rapid weight loss. The facility’s Weight Management policy, revised in 12/2024, required monitoring and intervention for residents with sudden changes in nutritional intake, a loss or gain of 5 lbs. since the last recorded weight, or weight changes greater than 5% in one month, among other thresholds. The resident was admitted in mid-January 2026 with a goal weight of 185–190 lbs., and the nutritional assessment dated 1/21/26 documented “no weight change” despite subsequent weight records showing a decline. The Weight and Vitals Summary showed the resident’s weight decreased from 187 lbs. on 1/15/26 to 180 lbs. on 1/24/26 (a 7 lb. loss in nine days), and then to 175 lbs. on 2/1/26, totaling a 12 lb. loss (approximately 6.4%) in less than a month.

Despite these documented changes, the facility did not address the resident’s significant weight loss in a timely manner. The resident’s weight remained 175 lbs. on 2/8/26, and an IDT Progress Note dated 2/9/26 recorded no change for one week, a 5 lb. loss over two weeks, and a 12 lb. (6%) loss over three weeks since admission. During interview, the RD stated she received copies of the weekly weights and acknowledged that a 7 lb. weight loss in nine days would be concerning and require follow-up, and that the resident had experienced significant weight loss of 6% from admission. The RD reported that she did not follow up with the resident until 2/9/26 and stated that, ideally, she should have followed up earlier. The Administrator, Administrator Assistant, ADON, and DON were informed of and acknowledged these findings.