Failure to Manage Severe Weight Loss in Resident with Gastrostomy Tube
Summary
The facility failed to ensure adequate nutritional management for a resident receiving gastrostomy tube feeding, resulting in severe weight loss. The resident, who had a history of muscle wasting, non-Hodgkin lymphoma, and multiple pressure ulcers, experienced a significant weight loss of 25.8 pounds, equating to 21.6% of their body weight over a two-month period. Despite the resident's care plan indicating a goal to prevent weight loss exceeding 5% per month, the facility did not conduct a change of condition assessment or monitor the resident's weight and nutritional status closely. The licensed nurses did not notify the resident's physician or responsible party of the significant weight loss, nor did they inform the registered dietician in a timely manner to evaluate the resident's nutritional needs. The interdisciplinary team failed to meet to develop interventions to prevent further weight loss, and the resident's care plan was not updated with measurable goals to address the weight loss. Additionally, the facility did not document the resident's weight changes accurately or consistently, leading to a lack of timely interventions. The resident's weight loss was not addressed adequately, and the facility's staff did not follow the established protocols for monitoring and managing significant weight changes. The lack of communication and documentation among the care team contributed to the resident's continued weight loss, placing them at risk for malnutrition and dehydration. The facility's failure to implement appropriate interventions and notify relevant parties resulted in a deficiency that posed a risk to the resident's health.
Removal Plan
- A change of condition assessment, SBAR for severe weight loss was completed, which included vital signs, pain, laboratory results reviewed and obtained new physician orders for adding Liquacel and to increase GT feeding to 55cc/hr.
- The assistant director of nursing conducted another assessment, indicating the Resident 188 remained at his baseline condition with normal vital signs, and without any sign of distress.
- The IDT members, including the RD, conducted an IDT care plan meeting. During the meeting, the IDT members addressed Resident 188's overall condition with severe weight loss. The physician instructed to start weekly weight for four weeks and repeat the comprehensive metabolic panel.
- RNA 1 will receive a performance correction notice, and a one-on-one in-service by the DON regarding weight documentation, emphasizing the importance of recording the weight on the same day it was measured.
- The weights management in-service was initiated until all licensed nurses, including part-time and night shift will be completed. Any licensed nurse unable to attend the in-service due to part time status, emergency or leave of absence has been removed from the schedule and must be given an in-service prior to returning to work.
- The DON and ADON initiated review of all residents' weight records for the past 30 days to ensure that all significant or severe weight changes had proper assessments, RD recommendations, MD notifications, and updated plan of care.
- The DON and the ADON will conduct monthly in-services to licensed nurses regarding weight management for 3-months, covering the following details: Conducting a change of condition assessment for significant or severe weight change.
- The DON and/or designee will repeat a monthly in-service for three months to RNA responsible for weights documentation, to ensure all weights are recorded on the same day it is measured.
- The DON created a weight management monitoring log, including significant or severe weight loss.
- The DON/ADON will meet with the RNA weekly for four weeks, then monthly for three months to ensure timely weight documentation.
- The DON/ADON will participate in weekly weight management meeting and document the findings with corrective actions in the monitoring log.
- The DON/ADON will monitor weight variance through weekly weight meeting to ensure all residents with weight variance (significant or severe) will be addressed. The DON will discuss weight management related findings during the monthly QA meeting for three months to ensure ongoing compliance with the state and federal regulations.
Penalty
Resources
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The facility failed to consistently document meal intake for two residents who had significant weight loss or were at nutritional/dehydration risk, despite care plans and physician orders identifying the need for monitoring. One resident with dementia, diabetes, and a history of significant weight loss had only about one‑third of meals documented over a month, with many days lacking any recorded intake, even though she was ordered a regular diet and supplements and was identified as at risk for malnutrition. Another resident with ESRD, respiratory failure, CHF, and on dialysis had multiple missing meal percentage entries across two months, including entire days without any documented intake, despite being care planned for nutritional risk. Staff interviews confirmed that meal intakes were expected to be documented in the EMR and that trays for residents away at appointments should be saved and offered later, but the Administrator and DON acknowledged that required intake documentation was missing.
The facility failed to provide ordered nutritional supplements with meals for two residents who required assistance and monitoring for nutrition and hydration. One resident with dementia, dysphagia, and severe cognitive impairment, fully dependent on staff for feeding, had orders for a health shake with meals and a magic cup to be given with meals and alternated with bites of food, but was only given the regular breakfast items without the health shake and without the magic cup being offered as ordered. Another resident with hyperkalemia, chronic fatigue, and moderate cognitive impairment, who was at risk for altered nutrition and had an order for a magic cup supplement with each meal, was observed eating breakfast without being offered the supplement. A CNA reported being unaware of some of these supplement orders despite diet cards in the kitchen, and the Administrator reported there was no policy on supplemental orders.
The facility failed to consistently document meal intake percentages for three residents who were care planned as being at risk for malnutrition, dehydration, and significant weight loss, and who required extensive assistance with eating and other ADLs. Despite care plan interventions directing staff to monitor and record meal percentages at each meal, record reviews showed numerous missing entries for breakfasts, lunches, and dinners over multiple months. A CNA reported documenting meal intakes after meals and not leaving before completing charting, while the DON stated that aides are expected to chart daily and that meal percentages are used to monitor nutritional status. Facility policy required nutrition documentation for all residents in accordance with regulatory and practice standards.
A resident with Alzheimer’s disease, CHF, metabolic encephalopathy, an unstageable sacral pressure ulcer, and essential tremor, who had impaired cognition and required staff assistance with eating, toileting hygiene, bed mobility, and transfers, did not have weights monitored according to the facility’s Weight Management policy. The policy required weights on admission, weekly for four weeks, and then monthly, but documentation showed only three weights were obtained, with no further weights recorded before the resident was transferred to the hospital. The UM confirmed both the policy requirements and the absence of additional documented weights, resulting in a cited deficiency for failure to follow the facility’s weight-monitoring protocol.
A resident with a history of UTIs, hypotension, protein-calorie malnutrition, and dysphagia had a dietary recommendation and physician order for an extra 240 ml of fluids with lunch and dinner to support hydration. Over an extended period, intake records showed low average daily fluid intake and no documentation that the ordered extra fluids were consistently provided. A supper meal ticket lacked the extra fluid order, observation showed only one standard beverage and a UTI supplement, and the DM reported being unaware of the extra fluid requirement, with no notation on the dietary reminder sheet. An LPN later confirmed the order existed, and the resident’s daughter reported ongoing concerns about inadequate hydration, dark urine, decreased urination, and recurrent UTIs.
Two residents experienced significant weight loss without appropriate individualized nutrition care planning or required weight monitoring. One resident with dementia and other psychiatric diagnoses had documented weight decline and a dietician‑ordered change in Med Pass supplements, but weekly weights were not obtained as required, the new supplement order was not entered for many days, and the care plan was not updated to reflect the weight loss. Another resident with neurologic and psychiatric conditions had multiple documented weight changes, but admission and weekly weights were not consistently taken, and no care plan was developed to address the weight loss, despite a dietician note identifying a significant one‑month weight change and ordering changes to tube feeding and continued monitoring.
Failure to Consistently Document Meal Intake for Residents at Nutritional Risk
Penalty
Summary
The deficiency involves the facility’s failure to consistently document meal consumption for residents with significant weight loss or identified nutritional risk, preventing adequate monitoring of their nutritional status. One resident with dementia, diabetes, depression, anxiety, and vitamin deficiencies was admitted at 154.4 pounds and had a documented downward weight trend to 140 pounds after three months and then to 130 pounds. Her care plan identified her as at risk for nutrition with a history of significant weight loss at one, three, and six months, with goals to avoid unplanned significant weight changes and interventions including a regular diet, offering substitutes, providing ordered supplements, and documenting consumption. Physician orders noted she was at risk for malnutrition and prescribed a regular diet and house supplements twice daily. However, review of her meal intake records over a 30‑day period showed that only 29 of 90 meals had documented intake, with no documentation at all for any of the three meals on 16 separate days and incomplete documentation on several other days. Staff interviews further confirmed the lack of consistent documentation for this resident. A CNA reported that the resident ate breakfast in the dining room and usually had lunch and supper with family in her room or while out on drives, and that her appetite varied by day. The CNA stated that if the resident ate less than 50% of a meal, staff would offer alternatives, but she was not aware of the resident receiving supplements or having weight loss, and there were no supplements available for the resident in the container at the nurses’ station that day. An LPN verified that the resident’s meal percentages were not being consistently recorded in the EMR, acknowledging that only about one‑third of the resident’s meals were documented and that this information was important for the dietitian when determining nutritional interventions related to weight loss. A second resident, admitted with end stage renal disease, respiratory failure, hyperlipidemia, and congestive heart failure, had impaired cognition and required set‑up/clean‑up assistance with meals and was care planned as being at nutritional and/or dehydration risk due to recent surgery, CHF, dialysis, increased needs, and skin alteration. Interventions included assisting with meals and providing the ordered diet. This resident had multiple missing meal intake entries over March and April, including entire days with no documented breakfast, lunch, or dinner, and numerous individual meals without recorded percentages. Interviews with dietary and CNA staff indicated that trays for residents away at dialysis should be returned to the kitchen, stored in the fridge, or placed in the server room until the resident returned, and that meal intakes should be documented in the computer. The Administrator and DON confirmed the missing meal percentage documentation, and facility policy required accurate records of residents’ food intake to be completed by assigned personnel.
Plan Of Correction
1. On 5/6/26 the Director of Nursing reviewed Resident # 5 and determined there was no ill effect related to the missing meal documentation and the resident's weight remains stable. On 5/6/26 the Director of Nursing reviewed Resident # 12 and determined there was no ill effect related to the missing meal documentation and the resident's weight remains stable. 2. Like Residents are identified as residents who receive meals from the facility. Utilizing the Meal Intake Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, an audit of identified residents will be completed by the Director of Nursing or designee to ensure they have diet orders in PCC and meal intake is being documented in PCC. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing designee will re-educate licensed nurses and STNA's on the Food Acceptance Policy to include documenting meal intake in POC. This education will be completed on or before 5/13/26. 4. Utilizing the Meal Intake Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit 4-6 residents weekly for four weeks, beginning 5/14/26 to ensure they have diet orders in PCC and meal intake is being documented in PCC. Noncompliance noted during audits will be corrected to ensure diet orders are in PCC and meal intake is being documented in PCC. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Failure to Provide Ordered Nutritional Supplements With Meals
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered nutritional supplements to residents as specified in their physician orders and care plans. One resident with severe cognitive impairment, dementia, depression, dysphagia, and dependence on staff for feeding had care plan interventions for staff to feed all meals and snacks and physician orders for a regular diet with pureed texture and mildly thick liquids. The care plan and orders included a health shake with meals for weight gain and a magic cup with meals, to be offered alternating with bites of food per speech therapy. During a breakfast observation, the resident was fed oatmeal, eggs, fruit, and thickened juice by a CNA, but the magic cup was not provided in between bites of food, and the health shake was not provided at all. The CNA confirmed awareness that the resident should receive a magic cup but did not know it was to be given between bites and was unaware of the health shake order, despite diet orders being available in the kitchen. Another resident with hyperkalemia, chronic fatigue, weakness, moderate cognitive impairment, and risk for altered nutrition and hydration status had care plan interventions to offer substitutes when meal intake was less than 50%, monitor weights, and provide nutritional supplements as ordered. The resident’s diet had been changed from mechanically altered to regular with thin liquids, and there was a physician order for a magic cup supplement with meals. During a breakfast observation, the resident was seen eating eggs, bacon, and toast without being offered a magic cup. The CNA later confirmed that the diet card indicated the resident should receive a magic cup with each meal but acknowledged that the supplement was not offered and that they were unaware of the order. The Administrator stated there was no policy on supplemental orders. This deficiency was cited under a complaint investigation.
Failure to Consistently Document Meal Intake for Residents at Nutritional Risk
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure meal intakes were consistently documented for residents identified as being at nutritional risk, which was necessary to maintain residents’ health and monitor nutritional status. For one resident with Huntington’s disease, dysphagia, abnormal weight loss, bipolar disorder, and adult failure to thrive, the care plan identified risks for altered nutrition, dehydration, and significant weight loss, with interventions that included monitoring and documenting meal percentages at each meal. Record review showed multiple missing meal intake entries across January, February, and March 2026 for this resident, including undocumented breakfasts, lunches, and dinners on numerous specific dates, despite the care plan requirement to document each meal. A second resident, admitted with Alzheimer’s disease, protein calorie malnutrition, major depressive disorder, and chronic kidney disease, was care planned as being at risk for malnutrition, altered fluid maintenance/dehydration, and significant weight loss, with interventions to monitor and document meal percentages for each meal. Review of this resident’s records revealed missing documentation of meal percentages for several breakfasts, lunches, and dinners in January, February, and March 2026. These gaps occurred even though the resident required substantial/maximal assistance with eating and was dependent on staff for several ADLs, and despite the care plan directive to document each meal consumed. A third resident with non-traumatic subdural hemorrhage, visual hallucinations, Down syndrome, chronic pain syndrome, and left foot drop was also care planned as being at risk for malnutrition, altered fluid maintenance/dehydration, and significant weight loss, with interventions to monitor and document meal percentages at each meal due to consuming less than 75% of meals and needing assistance with meals. Record review showed numerous missing meal percentage entries for this resident’s breakfasts, lunches, and dinners across January, February, and March 2026. CNA #122 stated that meal intakes are recorded after meals and that she does not leave her shift until documentation is complete, while the DON stated that aides are expected to chart daily, including meal percentages, and confirmed that meal percentages are used to monitor residents’ nutritional status. Facility policy on nutrition documentation required that nutrition documentation be completed on all residents in accordance with regulations and standards of practice.
Failure to Monitor Resident Weights per Facility Policy
Penalty
Summary
The facility failed to obtain and monitor a resident’s weights in accordance with its Weight Management policy, which required all residents to be weighed on admission, weekly for four weeks, and then monthly or as indicated by the physician. One resident with diagnoses including Alzheimer’s disease, an unstageable sacral pressure ulcer, metabolic encephalopathy, congestive heart failure, and essential tremor was admitted with impaired cognition, required moderate assistance with eating, and was dependent on staff for toileting hygiene, bed mobility, and transfers. Record review showed this resident was weighed on admission at 164 lbs and then on two subsequent occasions at 165.2 lbs and 164.2 lbs, with no further weights documented before the resident was hospitalized and did not return. In an interview, the unit manager confirmed the facility’s weight-monitoring expectations and verified that no additional weights were obtained or recorded for this resident beyond the three documented weights, despite the resident remaining in the facility until hospital transfer. This deficiency was cited as non-compliance with the facility’s weight management policy under Complaint Number 2709811.
Failure to Provide Ordered Extra Fluids for Hydration
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered fluids to maintain a resident’s hydration status. The resident had diagnoses including recurrent urinary tract infections, hypotension, gastric reflux, protein-calorie malnutrition, and dysphagia, and had a dietary recommendation for 1950 ml fluid intake daily. After a hip fracture and readmission, the dietitian documented a recommendation and an order was obtained for an extra 240 ml of fluids with lunch and dinner, and this was also reflected on a diet order and communication form. Fluid intake records from 02/11/26 to 03/12/26 showed the resident’s intake per meal ranged from 60–240 ml, with an average daily intake of 760 ml, and there were days with missing meal intakes and several recorded refusals. There was no evidence in the records or care plans that the ordered extra 240 ml of fluids at lunch and dinner was being consistently provided or documented. Surveyor review of a supper meal ticket showed no indication of the extra 240 ml fluid order, and observation of the resident at supper revealed only one 240 ml cup of beverage and a 120 ml cup of UTI supplement, not the ordered additional fluids. The Dietary Manager stated she was unaware of the extra fluid order and confirmed that special dietary instructions should appear on the meal ticket and a reminder sheet in the kitchenette; the extra fluid order was not listed on that sheet. An LPN reviewed the orders with the surveyor and confirmed the resident was supposed to receive extra fluids with lunch and dinner, but this had not been communicated to dietary. The resident’s daughter reported concerns about inadequate hydration, including decreased urination, dark urine, and recurrent urinary tract infections, and stated she did not feel her concerns about her mother’s hydration needs had been addressed.
Failure to Implement Individualized Nutrition Care Plans and Required Weight Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain individualized, comprehensive nutrition plans and appropriate weight monitoring for two residents, in accordance with its own weight assessment policy. For one resident with Alzheimer’s disease, dementia, and intermittent explosive disorder, the admission orders included a regular diet with Med Pass supplement and the care plan identified risk for malnutrition due to diagnoses, depression, and supplement use. However, the care plan was not revised or individualized to address subsequent weight loss. Weight records showed a decline from 121.2 lbs on admission to 110 lbs over several weeks, and weekly weights were not obtained as required during the first four weeks after admission. The registered dietician documented a significant 8% one‑month weight loss and ordered a change in the Med Pass supplement regimen and continued weight monitoring per physician order. Despite this, the original Med Pass order was not discontinued until 11 days later, and the new Med Pass order was not entered into the system or reflected on the MAR until that same later date. Interviews with the RD, the regional director of operations, and the DON confirmed that weights were not taken on admission and weekly for four weeks as required, that weights were not monitored weekly after the significant weight change, that the supplement order change from 01/19/26 was not entered until 01/30/26, and that the nutrition care plan was not updated to reflect the resident’s weight loss. For another resident with cerebral infarction, schizophrenia, and psychoactive substance abuse, the care plan did not include any plan for weight loss. Weight records showed an admission weight of 164 lbs, followed by weights of 166 lbs, 156 lbs, and 154 lbs, and the resident’s weight was not taken at admission or weekly for four weeks as required by policy. The RD later documented a significant 7% one‑month weight change and ordered changes to tube feeding (Jevity 1.5) and continued nutrition monitoring with weights per physician order. However, interviews confirmed that required admission and weekly weights were not obtained, that weekly weights were not taken after the significant weight loss, and that there was no care plan addressing the resident’s weight loss, contrary to the facility’s policy requiring multidisciplinary, individualized care plans for weight loss or impaired nutrition.
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