F0656

D

Failure to Care Plan for Significant Weight Loss Due to Delayed Weight Entry and Inaccurate MDS Data

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

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan addressing a resident’s significant weight loss. The resident was an older male with moderate cognitive impairment (BIMS score of 9) and 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 assessment dated 03/15/26 documented no or unknown weight loss, and his care plan dated 05/14/25 included a problem focus on dental health but did not include any focus, goals, or interventions related to nutrition or weight loss.

Record review showed that the resident’s weight declined from 148.2 lbs on 01/09/26 to 145.5 lbs on 02/10/26, and then to 122.4 lbs on 03/09/26, representing a documented 15.9% loss and 23.1 lbs lost between 02/10/26 and 03/09/26. There were no documented re-weighs after the 03/09/26 weight. A weights and vitals summary dated 03/24/26 reflected the 03/09/26 weight of 122.4 lbs with a noted percentage change, but this information was not incorporated into the MDS or care plan at the time of the Annual MDS assessment. The facility’s weekly resident review on 03/12/26 contained no triggers for weight loss in 30 days, and the resident was not reviewed for weight loss.

Interviews revealed that the MDS nurse relied on system alerts and available weight data when completing MDS assessments and stated that significant weight loss should trigger an alert and lead to updated assessments and care plan interventions. She reported that no alert appeared for this resident’s weight loss because current weights were not always entered into the system in a timely manner, and she used the data that were available, which did not reflect the significant loss. The DON stated that she was responsible for entering weights from paper records into the electronic system and acknowledged that the resident’s 03/09/26 weight was not entered by the time of the weekly review or the subsequent QAPI meeting, due to being behind on documentation. The DON also stated that the Activity Director took and recorded weights on paper without a running log, and that the facility’s policy required weights and documentation to be completed by the 10th of each month. As a result of these delays and omissions, the resident’s significant weight loss was not identified in the MDS, did not trigger review, and was not addressed in a comprehensive care plan as required by the facility’s Comprehensive Care Planning policy.