F0692

D

Failure to Implement and Document Nutritional Care Plan Interventions

Broadview Heights, Ohio Survey Completed on 01-15-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement and document nutritional care plan interventions for a resident with multiple medical conditions. The resident was admitted with diagnoses including type 2 diabetes mellitus with diabetic neuropathy, anxiety disorder, obstructive and reflux uropathy, acute osteomyelitis of the left ankle and foot, and Candida auris. The resident’s care plan, initiated shortly after admission and revised later, identified a potential for altered nutrition and hydration related to diabetes, altered mental status, tremors, anxiety, dysphagia, a mechanically altered diet, and other diagnoses. The care plan specified goals that the resident would avoid unplanned significant weight changes and would consume more than 75% of two meals daily, with interventions that included monitoring meal intakes and recording them on the STNA/CNA flow record.

Record review for the period immediately prior to the resident’s transfer to the hospital showed that these interventions were not carried out as planned. Aide charting from 02/07/25 through 02/22/25 contained no evidence that the resident was eating and no documentation of meal intake percentages. Progress notes for the same period also lacked any information about whether the resident was eating, what his meal intake was, or whether he refused meals. During interviews, the DON, the Regional Director of Clinical Operations, and the Social Services Designee confirmed there was no documentation in the medical record, including aide charting, to show that the resident was eating or that meal percentage intakes were recorded. The RDCO stated that the resident’s stable weights and frequent eating in the facility café were viewed as indicators that he was eating, but this was not supported by documented meal intake records as required by the care plan.