F0658

D

Failure to Complete Dietician-Requested Reweight and Timely Follow-Up of Oncology-Ordered Labs

Florissant, Missouri Survey Completed on 01-22-2026

Penalty

No penalty information released

Summary

The facility failed to ensure services met professional standards when staff did not obtain a repeat weight as requested by the registered dietician for a resident with multiple comorbidities, including diabetes, aphasia, dysphagia, dementia, and delusional disorder. The resident’s care plan identified a nutritional problem or potential nutritional problem, with goals to maintain weight within 5–10% of usual weight and consume at least 75% of 2–3 meals daily. The weight summary showed a decline from 192.5 lbs to 187.2 lbs and then to 166.2 lbs over three consecutive monthly weights, with no further weights documented. On a dietician progress note, a “weight warning” was documented with a request for a reweight. The restorative aide/CNA, who was responsible for obtaining and documenting weights, reported that the dietician’s reweight requests were communicated via email from the ADON and acknowledged that the resident was on the reweight list but the reweight could not be found in the record. When the resident was weighed during the survey, the weight was 163.7 lbs, confirming that the requested reweight had not been completed and documented within the expected timeframe.

The facility also failed to ensure that requested laboratory tests from an outside oncology provider were completed and followed up on in a timely manner for another resident with diagnoses including liver cancer, generalized muscle weakness, and Alzheimer’s disease. An order for a CBC and CMP was entered and marked complete, and progress notes documented calls to the oncologist’s office indicating that labs had been drawn and were pending. The lab report later showed that the CMP specimen was hemolyzed with a directive to call to reschedule, but there was no documented follow-up or redraw by facility staff. The oncology office social worker reported that after a December appointment, lab orders were sent with the resident and CNA, and also called and faxed to the facility, with instructions for labs to be completed between Christmas and New Year. The resident’s follow-up appointment was cancelled by the facility due to transportation issues, and the ordered labs were not actually completed until later at the oncology office, which had not received any lab results from the facility and was unaware of the hemolyzed specimen.