F0692

D

Failure to Provide and Monitor Adequate Meals and Snacks for Two Residents

Lapeer, Michigan Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure adequate and accurately monitored nutrition and hydration for two residents, including one who became ill with a respiratory infection and another who received hemodialysis. For the first resident, who had a history of stroke, depression, anxiety, hypothyroidism, and severe cognitive impairment (BIMS 5/15) and required assistance with all care, the care plan identified a potential for altered nutrition and hydration and directed staff to monitor and record how much the resident ate. In December, this resident developed an excessive cough and was later assessed with a respiratory infection, with an x-ray and antibiotics recommended. Progress notes show that the resident was transferred to the ER for right leg weakness and possible stroke and was diagnosed with low sodium, low potassium, weakness, and dehydration, treated with IV fluids, and then returned to the facility.

A detailed review of the electronic "Nutrition – Amount Eaten" task documentation for this resident from late December through early January revealed erratic and inconsistent charting that did not reliably capture meal intake. There were two separate intake documents with overlapping and contradictory entries, including multiple meals charted at the same time, meals documented before typical meal times, and conflicting percentages for the same time entry. On some days, only one meal was documented, and on other days there was no documentation at all, despite the resident being present in the facility and expected to receive three meals. Some entries were charted in batches and prior to meals, making it impossible to determine actual meal times or whether the resident received and consumed three meals per day. The registered dietitian reported she had last seen the resident in early December before the respiratory illness, had not reviewed the late December/early January intake documentation, and was unaware of the ER visit for low sodium, low potassium, and dehydration.

For the second resident, who had diabetes, end-stage renal disease on hemodialysis, heart disease, anemia, depression, anxiety, and a humerus fracture, the facility failed to ensure that breakfast or snacks were provided in relation to early-morning dialysis treatments. This resident was cognitively intact (BIMS 13/15) and required assistance with care. A confidential interview indicated the resident left for dialysis around 4:45 a.m., returned mid- to late morning, and did not receive a meal or food before leaving, nor a sack lunch or food to take along. The same source reported that the resident sometimes did not receive an evening snack and could go from the evening meal until nearly lunchtime the next day without food, and that the resident sometimes had to ask for the evening snack and did not always receive it. Dialysis communication forms repeatedly showed "Meal/Snack Sent" as "None," "No," or left blank, and the dialysis center’s documentation showed snack intake of 0 on those days, except for one dialysis supplement.

Further review of this dialysis resident’s records showed that the "Nutrition – HS Snacks" task documentation was not consistently completed, with multiple dates missing any record of whether a snack was taken and some dates marked "Not applicable." The resident’s care plans for diabetes, altered nutrition/hydration related to renal diet and fluid restriction, and hemodialysis three times weekly did not include interventions to provide HS snacks, pre-dialysis meals, or snacks/lunches to take to dialysis. The kitchen manager stated the resident left before the kitchen opened and that nothing was prepared the night before because she believed the resident did not want anything, but she did not know if this was true for each dialysis day. The registered dietitian stated sack lunches were available and believed the resident did not want one, and acknowledged that the care plan did not address nutrition from supper the night before dialysis through the time before or after breakfast, nor did it mention HS snacks. Overall, the documented practices and omissions show that the facility did not consistently offer or document meals and snacks necessary to maintain these residents’ nutrition and hydration as required by their conditions and care plans.