F0692

E

Failure to Maintain Nutritional Status and Monitor Weight for Resident With Dysphagia and Denture Issues

Burleson, Texas Survey Completed on 01-30-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain acceptable nutritional status and accurately monitor weight for a cognitively intact male resident with multiple diagnoses, including COVID-19, acute kidney failure, heart failure, Barrett’s esophagus with dysphagia, and difficulty swallowing. On admission, he was placed on a mechanically altered/pureed diet with thin liquids and required set-up assistance for eating and partial to moderate assistance with oral hygiene. The admission MDS documented loss of liquids/solids from the mouth and food holding in the cheeks, but oral/dental status was marked as having no denture issues. The care plan identified unplanned weight loss related to poor PO intake and included interventions such as supplements, an appetite stimulant (mirtazapine), monitoring and evaluating weight loss, and providing the ordered diet.

Speech therapy’s bedside swallowing evaluation documented oral and pharyngeal phase impairments, including anterior spillage, oral residue, and reflexive throat clearing, and noted that the resident declined solid trials and remained on a pureed diet. Subsequent speech therapy notes described ongoing concerns about food feeling stuck with mechanical soft trials and the need for further instrumental assessment. A nutritional assessment recorded that the resident did not like pureed foods, reported drinking 1–2 Ensure drinks daily, and that his dentures were too big due to weight loss. The dietitian recommended continuing the current diet, adding Ensure twice daily, and Med Plus twice daily. A weight change communication form showed a significant weight loss of 16 pounds (9%), with a recent weight of 162 pounds, and noted his pertinent history and current use of diuretics.

The facility’s weight records showed an admission weight of 170 pounds, followed by 162 pounds and then 155 pounds at discharge, but weekly weights for the first four weeks after admission were not consistently obtained as required for residents with weight loss, new admissions, and readmissions. Staff interviews revealed gaps in communication and documentation regarding the resident’s oral and denture care needs and assistance with eating. A hospital RN reported that the resident was admitted to the hospital without dentures, with impacted food in his gum line and a large glob of pink denture adhesive lodged in the back of his throat that required suctioning, raising concerns about oral care at the facility. A family member stated the resident had difficulty with dentures due to weight loss, was having problems eating, and that staff were supposed to assist with feeding and mouth cleaning. A CNA stated there was no written place to see that a resident required oral or denture care and that such information was passed only verbally, while an LVN acknowledged the resident’s weight loss, swallowing difficulty, food pocketing, and occasional need for feeding assistance, and was unsure why weekly weights were not obtained. The DON stated that the restorative aide was responsible for weekly weights on triggered residents and that the ADON was responsible for monitoring completion, and that not weighing residents weekly could delay interventions.