F0580

D

Failure to Notify Physician and Address Significant Resident Weight Loss

Fort Worth, Texas Survey Completed on 03-24-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to immediately consult with a resident’s physician when there was a significant change in the resident’s nutritional status, specifically a substantial weight loss. The resident was an older male with multiple active diagnoses, including non-Alzheimer’s dementia, Parkinson’s disease, depression, schizophrenia, history of alcohol abuse, cirrhosis, metabolic encephalopathy, and a benign neoplasm of the sigmoid colon. His Annual MDS dated mid-March reflected a weight of 145 pounds and no or unknown weight loss, and his care plan included a focus on dental health problems but did not include a focus or interventions related to nutrition or weight loss. Laboratory results from early March showed a low glucose level of 68 and a slightly low albumin level of 3.3.

Record review of the resident’s weights showed that he weighed 148.2 lbs in early January, 145.5 lbs in early February, and 122.4 lbs in early March, representing a 15.9% loss and a 23.1 lb decrease between early February and early March. There were no documented re-weighs after the March weight, and there were no physician orders addressing weight loss despite this significant change. The facility’s weekly resident review on March 12 did not list any triggers for weight loss in 30 days, and the resident was not reviewed. The DON later stated that she entered all weights into the electronic health record but had missed entering this resident’s March 9 weight, which prevented the system from triggering an alert for weight loss and from identifying the change during the weekly review and MDS update.

Interviews with staff showed that CNAs and the Activity Director observed the resident to have a good appetite and to usually eat most or all of his food, and the resident himself reported that he felt well, did not feel he was losing weight, and felt he received enough food, including preferred cultural foods. The DON stated that a weight loss of over 5% should have been immediately reported to the MD, RD, and family, and acknowledged that missing significant weight loss could place residents at risk of untreated serious health conditions. The MD stated his expectation was to be notified of any weight change over 5% gain or loss and that he had not been informed of this resident’s significant weight loss. The RD stated that if a resident had more than 5% weight loss in one month, she would expect immediate notification and interventions such as re-weighs, fortified diet, supplements, and weekly weights. The facility’s written policies on notifying the physician of change in status and on resident weights required timely weighing, review of weights for significant changes, re-weighs within 24 hours, and notification of the physician and family for significant weight loss, but these procedures were not followed for this resident’s documented 15.9% weight loss.

The DON further explained that the Activity Director was responsible for obtaining monthly weights and documenting them on paper, while the DON was responsible for entering them into the electronic system and reviewing them for significant changes. The facility did not keep a running log of weights on the paper document, and the Activity Director was not responsible for monitoring the numbers for significant changes. The DON stated that she was behind on documentation due to training and did not enter the resident’s March 9 weight until after the 15th of the month, which caused the weight loss to be missed during both the weekly resident review and the MDS assessment process. The Compliance Nurse stated that the expectation for significant weight loss was to re-weigh and notify the MD, RD, and family, and to update the care plan with interventions such as weekly weights and a nutrition risk program, but could not state whether the resident’s weight was accurate or why there was no documented re-weigh. Overall, the facility did not follow its own policies and did not immediately notify the physician or implement care plan interventions in response to the resident’s significant weight loss.