F0692

D

Failure to Initiate RD-Recommended Supplements and Monitor Significant Weight Loss

Raleigh, North Carolina Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure adequate nutrition and monitoring for a resident with complex medical needs, including not initiating an RD-recommended supplement, not obtaining weekly admission weights per facility practice, and not evaluating significant weight loss and declining albumin. The resident was admitted after a complicated hospitalization that included spinal decompression surgery, an epidural hematoma requiring additional surgery, sepsis from hospital-acquired pneumonia, and multiple chronic conditions such as COPD, diabetes, hypertension, obesity, osteoarthritis, neuropathy, and a history of alcoholism and illegal drug use. The hospital discharge summary documented a last hospital weight of 240 pounds 4.8 ounces, while the facility admission weight on the same date was 226 pounds. On admission, the resident’s albumin was 3.5, within normal limits, and the care plan identified risk for weight loss or malnutrition related to recent acute illness, hospitalization, and chronic disease, with interventions including RD consult as needed, recording meal intake percentages, reviewing dietary preferences, and providing a therapeutic diet as ordered.

On 10/31/25, the RD assessed the resident and documented that he had MASD to the buttocks, was on a diabetic diet, and was consuming 50–75% of his meals. The RD noted that his intake did not appear to consistently meet his estimated nutritional needs and recommended Med Plus 1.7, 90 ml twice daily with medications. However, review of physician orders for October and November showed that Med Plus was not ordered following this recommendation, and the RD later stated she did not know why nutritional support had not started at that time. The DON reported that residents were to be weighed weekly for four weeks after admission and then placed on an individualized schedule, and that the RD typically reviewed any abnormal weights. Nurse #1, who helped oversee weekly weights, reported that the facility missed weighing the resident during the first four weeks after admission as required by their system, and that the first weight she could find after admission was 197.2 pounds on 11/14/25, reflecting a significant loss from the 226-pound admission weight. This weight was not entered into the electronic record, and there was no documented assessment or follow-up of the weight loss at that time.

During this same period, the resident’s skin condition worsened. On 10/24/25, the Wound Nurse documented MASD and an open area on the right buttock. By 11/10/25, the Wound Nurse documented four pressure sores, three unstageable and one Stage II, including one described as black and bleeding. On 11/12/25, the Wound Nurse documented multiple pressure sores, one necrotic with foul odor, and noted that the Wound NP planned to order labs. Labs on 11/13/25 showed the resident’s albumin had dropped to 3.0, an abnormally low level and a 0.5 decrease from 10/24/25. There was no documentation from 11/14/25 through 11/24/25 of an assessment of what was contributing to the resident’s weight loss and low albumin or of possible interventions. The RD did not evaluate the resident again until 12/8/25, after a hospitalization for worsening pressure sores and readmission on 12/5/25, at which time she documented that the resident had lost more than 30 pounds in two months, had three pressure sores present on admission, and had increased nutritional needs for wound healing. She again recommended Med Plus 1.7 and additional supplements, which were ordered and started on 12/10/25, marking the first time the Med Plus order appeared on the MAR since her initial recommendation on 10/31/25. Throughout this period, there was no documentation that weight loss or nutritional concerns were discussed at the 11/12/25 care conference, and key staff, including the MDS nurse, were not familiar with the resident’s weight loss or related interventions, contributing to the failure to timely address the resident’s nutritional decline.

The deficiency also includes the facility’s failure to obtain admission weights per its stated system for another newly admitted resident, which prevented establishment of individualized weight monitoring timeframes. The DON stated that residents were to be weighed weekly for four weeks after admission, with the first four weights used to determine future monitoring schedules, and that Nurse #1 helped oversee weekly weights. However, Nurse #1 reported that the facility had missed weighing the resident during the first four weeks following initial admission, and that the 11/14/25 weight was the first weight she could locate after the 10/23/25 admission weight. This gap in weight monitoring, combined with the failure to act on the RD’s supplement recommendation and the lack of documented evaluation of significant weight loss and declining albumin, formed the basis of the cited deficiency for failure to provide sufficient food and fluids to maintain the resident’s health.