Failure to Follow NPO Orders and Ensure Nutritional Safety
Summary
The facility failed to provide appropriate nutritional treatment and services for a resident with dietary orders for nothing by mouth (NPO). Upon admission, the resident had a history of pneumonia, dysphagia, respiratory failure, and required a gastrostomy tube (G-tube) for nutrition. Despite clear orders and documentation indicating the resident was NPO and at high risk for aspiration, staff did not properly assess or clarify dietary needs at admission. On the day of admission, an LPN provided the resident with two ham and cheese sandwiches and ice water, without confirming the hospital discharge orders or recognizing the presence of a G-tube. This resulted in the resident aspirating and subsequently being hospitalized for aspiration pneumonia. The deficiency was further compounded when, after the resident's return to the facility, a food tray was again provided to the resident despite ongoing NPO orders and clear recommendations from speech therapy. The meal ticket system failed to reflect the correct NPO status, and a CNA unfamiliar with the resident gave the food tray, which led to the resident having food in his mouth. The error was identified and corrected by a supervisor, but not before the resident was exposed to further risk. Interviews with staff confirmed that communication breakdowns occurred between nursing, dietary, and therapy departments, and that the meal ticket system did not always accurately display specialized diets. Throughout the resident's stay, there were multiple documented instances of aspiration, pneumonia, and hospitalizations directly related to the failure to follow NPO orders. Staff interviews revealed that the admitting nurse did not verify discharge orders upon admission, and that subsequent communication lapses and system errors led to repeated provision of food to the resident. The facility's own policies required timely review and clarification of dietary orders, but these were not consistently followed, resulting in the resident not receiving the necessary care and services to meet nutritional needs.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Follow Dietician Weight Monitoring and Feeding Recommendations: A resident with AD, aphasia, dysphagia, and protein-calorie malnutrition had a care plan and physician orders addressing nutrition and feeding support, but the facility did not complete the ordered weekly weights to establish a baseline after readmission. Records showed significant weight fluctuation, poor PO intake, pocketing of food and meds, and dependence on staff for feeding and fluids, while CNAs described the resident as weak, lethargic, and needing supervision, prompting, and redirection.
A resident with CHF, diabetes, COPD, and morbid obesity had a physician order for daily weights, but the record showed weights were documented only sporadically and most missed weights had no refusal documentation or provider notification. Staff interviews showed confusion about whether the order was active, and the DON stated the resident had a history of noncompliance with weights, fluid restrictions, medications, and treatments.
A resident admitted with muscle wasting and atrophy had documented weight changes from 164 lbs to 178.6 lbs, then dropped to 156.6 lbs, triggering a Dietitian note for significant weight loss and a reweight request. The reweight was delayed, the resident was later documented at 153 lbs, and no further Dietitian follow-up or additional nutritional interventions were put in place after the weight loss was identified; staff also did not follow the facility’s weekly weight monitoring schedule for newly admitted residents.
A resident with stroke-related deficits, CHF, hypothyroidism, gastritis, and a GI bleed was identified as being at risk for altered nutrition and fluid imbalance. After the resident became fatigued and labs showed elevated BUN, creatinine, and a low GFR, a DT documented a recommendation for the NP to review the resident for IV fluids. However, the recommendation was not shown to have been relayed to the provider, and the NP later stated she was not aware of it.
The facility failed to provide ordered nutritional supplements to three cognitively impaired, dependent residents. Meal tickets and care plans called for items such as ice cream, yogurt, pudding, applesauce, and whole milk, but during a lunch observation one resident had no ice cream, another had no yogurt, and a third had no ice cream on the tray. Staff said the kitchen had stopped sending these items on trays and nursing was expected to get them from the pantry, but the pantry was often not stocked and the residents did not receive the ordered items.
A resident at risk for weight changes did not have all ordered weekly weights documented. The care plan directed weights per MD orders, but the nurse failed to record one of the scheduled weekly weight checks, and the corporate nurse acknowledged that some ordered weights had been missed for some residents.
Failure to Follow Dietician Weight Monitoring and Feeding Recommendations
Penalty
Summary
The facility failed to implement dietician recommendations for a resident with Alzheimer’s disease, aphasia, dysphagia, and protein-calorie malnutrition. The resident’s care plan identified risk for dehydration, weight loss, or malnutrition, and physician orders included use of a maroon spoon for all meals to control oral intake and a mechanical soft diet with thin liquids. The most recent MDS also documented impaired daily decision-making, significant recent weight loss, and unhealed pressure injuries. A nutritional assessment documented weekly weights times four to re-establish a baseline weight after readmission, but the weight summary showed those weekly weights were not completed. The resident’s weights fluctuated significantly over the months reviewed, including a drop from 171.0 lbs to 141.5 lbs. The record also showed poor intake, with the resident dependent or requiring maximum assistance with eating on multiple days and consuming only 25-50% of meals during the period reviewed. Progress notes documented that the resident was eating less than 25% of meals, pocketing food and medications, and needing escalation of nutritional interventions. CNA interviews described the resident as weak, lethargic, not feeding self consistently, requiring supervision, redirection, prompting for fluids, and often eating only 25-30% of meals. The RDCS stated there were no weights per the dietician recommendations, and the dietician stated the weekly weights were ordered to establish a baseline after readmission.
Failure to Document Ordered Daily Weights
Penalty
Summary
The facility failed to routinely document physician-ordered daily weights for Resident B, who had diagnoses including CHF, diabetes, COPD, and morbid obesity. His MDS assessment indicated he was cognitively intact, non-ambulatory, and used a wheelchair for mobility. The current order summary showed an order placed for daily weights, but the order did not include parameters for notifying the physician for weight gain or loss within a defined time period. Weights were documented only on a few dates in the clinical record, and the majority of dates without weights had no documentation showing that the resident refused the weight or that the attending physician or NP was notified that the weight was not obtained. During interview, Resident B denied that daily weights had ever been obtained at the facility. An LPN stated she was unaware of any current residents who were to have daily weights, while another LPN identified Resident B as the resident with that order. The DON stated Resident B had a history of noncompliance with care, including refusing daily weights, and said the doctor and NPs were aware of his noncompliance with fluid restrictions, weights, medications, and treatments. The RD stated she believed the daily weight order had been discontinued after the resident signed a waiver for fluid restrictions and noted he was noncompliant with many aspects of care, including refusing weights at times. The facility later provided policies on weight assessment and provider notification, which stated that resident weights were to be monitored and recorded and that the physician or practitioner was to be informed of diagnostic results or changes in condition in a timely manner. The DON also stated the facility did not have a specific policy or procedure regarding implementation of physician orders and that the expectation was that all physician orders were followed.
Failure to Monitor Weight Loss and Nutritional Needs
Penalty
Summary
Facility staff failed to assess and monitor Resident #4’s nutritional needs and intervene in a timely manner. The resident was admitted in February 2026 with a diagnosis including muscle wasting and atrophy. The medical record showed weights of 164 pounds on admission, 173.4 pounds on 3/6/26, and 178.6 pounds on 4/9/26, followed by a documented weight of 156.6 pounds on 5/20/26. On 5/22/26, the Dietitian documented that the resident had fair to good PO intake and was triggering for significant weight loss, with a reweight requested and change to be assessed after the reweight was obtained. The resident was not reweighed until 6/2/26, 13 days later, when the documented weight was 153 pounds. The resident was not seen by the Dietitian after the reweight and transferred out of the facility on 6/9/26. The Dietitian stated weights should be weekly on admission times 4 then monthly, and no further interventions were put in place after the 5/20/26 documented weight loss. The facility’s Weight Monitoring policy stated newly admitted residents are to be monitored weekly for 4 weeks, and the Regional Nurse confirmed the resident was not weighed weekly on admission times 4 and no additional nutritional interventions were put in place after the documented weight loss.
Failure to Communicate Dietary Recommendation for IV Fluids
Penalty
Summary
The facility failed to inform the nurse practitioner of a dietary recommendation to review the need for IV fluids for a resident with multiple medical conditions, including hemiplegia and hemiparesis following cerebral infarction, chronic systolic congestive heart failure, hypothyroidism, mild gastritis, and a gastrointestinal bleed. The resident’s care plan identified risk for altered nutrition and fluid imbalance related to these conditions, along with episodes of meal intake less than 50 percent, significant weight loss, fluid shifts, and frequent urinary incontinence. On 05/19/26, the resident was seen by an NP for fatigue and was described as very tired during the exam. A chest X-ray, CBC, BMP, and TSH were ordered, and the NP noted there was no suprapubic tenderness and would hold off on IV fluids. The next day, labs showed elevated BUN, creatinine, and a reduced GFR. A dietary note documented a recommendation for the NP to review the resident for IV fluids, and nursing was aware and would contact the NP. However, there was no evidence that the dietary recommendation was relayed to the provider. A nursing note stated lab results were reported and new orders were received, but it did not show that the IV fluid recommendation was communicated. The NP later documented follow-up for pneumonia and additional antibiotics, but there was no indication she had been advised of the dietary recommendation. During interviews, the LPN stated she did not recall speaking with the DT or a dietitian about IV fluids, and both NPs stated they were not aware of the recommendation.
Missed Nutritional Supplements on Meal Trays
Penalty
Summary
The facility failed to provide nutritional interventions to assure that three residents received ordered food items intended to maintain proper weight and health. Resident 5 was cognitively impaired, dependent on staff for daily care tasks, and had a care plan directing whole milk with all meals and ice cream with lunch and supper. Resident 7 was cognitively impaired, dependent on staff, and had a care plan directing yogurt with lunch for additional protein. Resident 8 was cognitively impaired, dependent on staff, and had a care plan directing ice cream with all meals. During the lunch meal observation, Resident 5’s meal ticket indicated ice cream with lunch, Resident 7’s ticket indicated pudding, yogurt, or applesauce with lunch, and Resident 8’s ticket indicated pudding, yogurt, or applesauce with every meal. Resident 5 did not receive ice cream on the lunch tray, Resident 7 did not receive yogurt, and Resident 8 did not receive ice cream. Staff called the kitchen to send the items to the dining room, but Residents 5 and 8 still did not receive ice cream after the meal, and Resident 7 was told to remain after eating to wait for yogurt. Staff interviews confirmed the kitchen had not been sending yogurt, ice cream, pudding, or applesauce on trays, that these items were often not stocked in the pantry, and that nursing staff were expected to provide ice cream from the pantry after the kitchen stopped placing it on warm lunch trays.
Missed Ordered Weekly Weights
Penalty
Summary
The facility failed to follow a physician’s order for weekly weight monitoring for Resident #7, who was identified in the care plan as being at risk for weight changes and whose goal was to improve or maintain current weight. The care plan directed staff to weigh the resident per physician orders and as needed. A physician’s order required weekly weight checks on Wednesdays for four weeks on the 7:00 a.m. to 7:00 p.m. shift by the nurse, but the resident’s weight record showed only three documented weights and no recorded weight for one ordered weekly check. The corporate nurse stated that weekly weights were supposed to be done on Wednesdays and acknowledged that some weights had been missed for some residents and that a process change was needed.
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