F0692

D

Failure to Identify and Address Significant Weight Loss and Nutritional Status

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

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to recognize, evaluate, and address a resident’s significant weight loss and nutritional status. 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 a weight of 145 pounds and indicated no or unknown weight loss, and his care plan contained a focus on dental health problems but no focus or interventions related to nutrition or weight loss. The resident’s diet order was for a regular diet with mechanical soft texture and regular consistency, and there were no physician orders addressing weight loss.

Weight records in the EHR showed that the resident weighed 148.2 lbs on 01/09/26, 145.5 lbs on 02/10/26, and 122.4 lbs on 03/09/26, reflecting a documented 15.9% loss between 02/10/26 and 03/09/26. There were no documented re-weighs within 24 hours as required by facility policy, and the facility’s weekly resident review on 03/12/26 showed no triggers for weight loss in 30 days, so the resident was not reviewed. Lab work from 03/02/26 showed a low glucose of 68 and a slightly low albumin of 3.3, but there was no documentation that these findings were linked to an evaluation of his nutritional status or weight loss. The DON later acknowledged that she had not entered the 03/09/26 weight into the electronic record in a timely manner, which resulted in the resident not triggering for review and the MDS assessment remaining inaccurate regarding weight loss.

Staff interviews and observations further demonstrated that the significant weight loss was not recognized or acted upon. The CNA reported that the resident usually ate all his food, preferred outside food, and appeared to have lost a little weight, which she stated nurses were aware of, but there was no documentation of follow-up. The DON stated that the resident did not appear physically smaller, that no nurses had reported concerns, and that she must have missed the resident’s weight loss when entering weights into the system. The Activity Director, who was responsible for obtaining monthly weights and had weighed the resident on 02/10/26 and 03/09/26 using the mechanical lift scale, stated she wrote the weights on paper and gave them to the DON, was not responsible for entering them into the EHR, and had not noticed any physical changes in the resident’s weight. The facility’s written policy required monthly weights by the 10th, review of all weights by the DON or designee, re-weighs within 24 hours when indicated, and specific actions for significant weight changes, but these procedures were not carried out for this resident, resulting in the failure to maintain acceptable parameters of nutritional status and to address a documented significant weight loss.

Additional interviews with the MD, RD, Compliance Nurse, and other staff confirmed that the expected process for significant weight loss—re-weighing, notifying the MD, RD, and family, updating the care plan, and implementing interventions such as fortified diets, supplements, and weekly weights—was not initiated because the weight loss was not identified through the facility’s monitoring systems. The MD stated he expected notification for weight changes over 5% and consultation with the RD, but he was not informed of the resident’s significant weight loss. The RD stated she would expect immediate notification for more than 5% weight loss in one month and would advise re-weighs and nutritional interventions, but she reported that the resident’s weight had been considered stable and that she had no recollection of weight concerns. The Compliance Nurse described the facility’s expectations for managing significant weight loss, including re-weighs, notifications, care plan updates, and staff in-servicing, but could not confirm the accuracy of the resident’s weight or explain the lack of a documented re-weigh. Overall, the facility did not follow its own weight monitoring policy or implement appropriate assessment and care planning in response to the resident’s documented 15.9% weight loss.