F0641

D

Inaccurate MDS Assessment Due to Missed Significant 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 ensure an accurate MDS assessment for a resident who experienced significant 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 03/15/26, documented him as 66 inches tall and 145 pounds with no or unknown weight loss, despite electronic health record (EHR) vitals showing a substantial decrease in weight over the preceding months.

Record review showed the resident’s weights as 148.2 lbs on 01/09/26, 145.5 lbs on 02/10/26, and 122.4 lbs on 03/09/26, with no documented re-weighs. A weights and vitals summary dated 03/24/26 reflected that the 03/09/26 weight of 122.4 lbs represented a 15.9% loss (23.1 lbs) from the 02/10/26 weight. The resident’s care plan, dated 05/14/25, contained a focus on dental health problems with related interventions but did not include a focus or interventions regarding nutrition or weight loss. A weekly resident review document from 03/12/26 showed there were no triggers for weight loss in 30 days and the resident was not reviewed.

In interviews, the MDS nurse stated she had been in the role for about 11 months and that significant weight loss should trigger an alert in the system for MDS updating. She reported that when she completed the resident’s annual MDS on 03/15/26, there was no alert for weight loss and that current weights were not always entered into the system immediately, so she used the data available at the time. The DON stated that weekly meetings were held to review residents who triggered alerts for ADL declines, including weight loss, but the resident did not trigger because the 03/09/26 weight had not been entered. The DON acknowledged she was behind on documentation due to training and did not enter the 03/09/26 weight until after the 15th, causing the resident’s significant weight loss to be missed during both the weekly review and the MDS update, and resulting in an inaccurate MDS assessment and missed opportunity to identify the weight loss. The facility’s comprehensive care planning policy required use of the MDS to identify needs and revise care plans after each MDS assessment, but this process did not occur for the resident’s weight loss because the data were not timely entered and did not trigger further assessment or care planning.