F0692

E

Failure to Provide Required Meal Assistance and Address Significant Weight Loss

Olympia, Washington Survey Completed on 01-07-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide required assistance and supervision with meals and to promptly identify and address weight loss for multiple residents. One resident with dementia, a history of stroke, swallowing difficulties, and documented aspiration precautions was care planned and ordered to receive 1:1 assistance and supervision with meals, including cues to eat and encouragement to go to the dining room. Despite this, meal observation on two separate dates showed the resident eating independently in bed without staff present or assisting, and staff interviews revealed inconsistent understanding of the resident’s need for 1:1 supervision. Nursing assistants reported that staffing levels made it difficult to supervise residents who required it and, at times, the resident was left to eat independently, contrary to the care plan, dietary ticket, and physician orders.

Another resident, admitted with a colostomy and hypothyroidism and care planned as at risk for weight loss due to advanced age, experienced a significant decline in weight over approximately two months, from about 167 pounds to about 155 pounds. The nutritional assessment had set a goal of no weight loss through the review period and noted surgical abdominal wounds, but the medical record contained no documentation addressing this weight loss. Staff interviews confirmed that weight loss was supposed to be addressed at a weekly weight loss meeting and that findings were entered into a computer system rather than the medical record, resulting in no documented assessment or interventions in response to this resident’s weight loss.

A third resident with dementia and congestive heart failure, care planned and ordered to receive assistance with tray setup, 1:1 and intermittent supervision, and to be positioned bolt upright for meals, was observed with a meal tray left on the bedside table without setup and with the head of bed at about 45 degrees. The resident initially made no attempt to eat and later had to pull their body toward the tray to reach the food due to the bed position, with no staff present during the observation period. The dietary ticket and order details documented the need for 1:1 assistance and upright positioning, but a nursing assistant stated the resident did not require assistance with meals. Weight records showed this resident had notable weight loss over several months, and staff acknowledged that the weight loss should have been addressed at weekly meetings and documented in the medical record, but no such documentation or response was present.