Failure to Monitor and Follow Up on Poor Nutritional Intake for a Resident With Dysphagia
Penalty
Summary
The deficiency involves the facility’s failure to provide nutritional and hydration care and services consistent with a resident’s comprehensive assessment and care plan. The resident had diagnoses including dysphagia, UTI, and adult failure to thrive, with severely impaired cognitive skills and a need for moderate to maximal assistance with ADLs. The care plan for nutritional problems and dehydration risk, initiated on 12/17/2025, included goals to prevent malnutrition and interventions such as RD evaluation with diet change recommendations as needed and weekly or monthly weights as ordered. A physician order dated 12/26/2025 directed staff to monitor episodes of poor oral intake every shift and document meal percentages. Record review showed that the RD documented in July 2025 that the resident weighed 97 lbs, had a usual body weight range of 120–130 lbs, was on a regular diet with mechanical soft, finely chopped texture, and that weights and PO intake would continue to be monitored. The weight record showed weights of 102 lbs on 7/29/2025, 105 lbs on 8/5/2025, 110 lbs on 9/3/2025, and 106 lbs on 12/4/2025, but there were no documented weights for October and November 2025. The January 2026 intake log indicated the resident typically consumed 0–25% of most meals, with 25–100% at other times, reflecting inconsistent and often poor intake. Staff interviews confirmed ongoing poor intake and lack of effective follow-up. CNAs reported the resident frequently refused to eat, would spit food out, throw food away, or eat only about 25% at dinner, sometimes refusing meals entirely even when offered alternate trays. An LVN stated the resident did not eat much, had little appetite, and mostly drank Ensure rather than eating food on the tray. The DON acknowledged that facility documentation showed the resident was not consistently eating, that the last RD progress note was from July 2025, and that there had been no RD follow-up regarding the resident’s nutritional needs and risk of nutritional problems and dehydration, despite the resident’s poor and inconsistent intake and lack of appetite. Facility policies required comprehensive, person-centered care planning, regular review and updating of care plans, and multidisciplinary assessment of nutritional needs, but the documented monitoring and RD follow-up did not occur as outlined.
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