Failure to Provide Ordered Double Protein Portions and Nutritional Supplements for Residents With Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate nutrition and ordered supplements to residents with identified nutritional risks and weight loss. One resident with severe protein calorie malnutrition, end stage renal disease, and multiple other diagnoses was ordered a liberal renal diet with double protein portions at all meals. The resident’s care plan and nutritional assessments identified him as at risk for malnutrition and documented that he would likely benefit from adding double protein to all meals. Despite this, observations on multiple days showed that his lunch trays did not include the ordered double protein portions, and some menu items such as salad and bread were missing without explanation, even though his diet card specified them. The same resident was also receiving dialysis three times per week and reported that on dialysis days he only received breakfast and dinner. He stated that the facility did not send a lunch with him to dialysis and that when he returned in the mid- to late afternoon, he was usually offered something to eat so close to dinner that he would then not eat the evening meal, resulting in only two meals on those days. He also reported that the food he received in his room was often cold and unappetizing, including plain pasta with no sauce and cold, burnt sausage and cold eggs and pancakes, which led him to eat very little. Weight records documented that his weight decreased from 172.6 pounds to 147.0 pounds between late November dates, a loss of 25.6 pounds or 14.83% in less than 30 days, and he confirmed a current weight in the mid‑140s when reweighed. A second resident with Alzheimer’s disease, major depressive disorder, GERD with esophagitis, and documented significant weight loss was ordered a regular diet with mechanical soft texture and nectar thick liquids, along with a daily health shake, Med Pass 2.0 three times a day for weight loss, and super cereal at breakfast. Her care plan identified risk for nutritional deficit and included providing nutritional supplements as ordered. The MDS documented that she was dependent for eating and had experienced weight loss of 5% or more in one month or 10% or more in six months, and the dietician’s note identified an 11% weight loss in six months and risk for malnutrition. However, over at least four consecutive lunch observations, the resident’s meal trays did not include the ordered health shake, even though it was highlighted on the diet card and staff, including CNAs and the Dietary Manager, acknowledged that the shake should have been provided and could not explain its absence. The facility’s own policy on weight assessment and intervention required that significant weight changes be confirmed and that the dietitian be notified in writing if verified, and stated that the multidisciplinary team would strive to prevent, monitor, and intervene for undesirable weight loss. In practice, the registered dietician reported being notified of the first resident’s significant weight drop but stated she was waiting for confirmation of the weight and had not heard back. For both residents, there were clear physician and dietician orders for enhanced nutrition and supplements, but observations and interviews showed that ordered double protein portions, health shakes, and complete meals were not consistently provided as specified, contributing to the identified deficiency in providing sufficient food and fluids to maintain residents’ health.
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