F0692

G

Failure to Monitor and Respond to Declining Intake Leading to Severe Weight Loss

Rockford, Illinois Survey Completed on 02-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to identify, document, and update nutritional interventions for a resident with known risk factors and a history of weight loss, resulting in severe weight loss. The resident had multiple diagnoses including diabetes, atherosclerosis of the aorta, asthma, hypothyroidism, GERD, cataracts, dysphagia, lack of coordination, and gait/mobility abnormalities, and was assessed as having moderate cognitive impairment and requiring supervision to eat. The care plan, initiated months earlier, identified risk for weight gain/loss related to diabetes and hypothyroidism and directed staff to monitor and document meal intake percentages at all three meals and to refer to the physician/dietitian if there was a 5% weight loss over 30 days or 10% over 180 days. The facility’s weight summary showed a weight of 128 pounds in July and 113.6 pounds on 1/6/26, with no subsequent facility weight obtained before the resident’s hospital admission on 1/16/26, when the hospital documented a weight of 80 pounds and severe protein-calorie malnutrition.

From 1/6/26 onward, documentation of the resident’s food intake was incomplete and inconsistent despite clear indications of poor intake. The facility’s meal intake records showed the resident consumed 0–25% of breakfast and lunch on 1/6/26 with no entry for the evening meal, no documented intake at all from 1/7/26 through 1/10/26, and refusals to eat on 1/11, 1/13, and 1/15. On 1/12, the resident ate 0–25% at breakfast and lunch, with no entry for the evening meal. A psychiatry note dated 1/15/26 recorded staff reports that the resident had not been eating and that after the family placed a spending limit on the resident’s food delivery app card, she reportedly stopped eating. A dietary progress note on 1/15/26, based only on chart review and not an in-person assessment, stated that the resident’s intakes had been poor, that she required 1:1 supervision with meals, and that she was on appetite stimulants and multiple nutritional interventions, but it did not prompt a new weight or updated interventions in response to the recent decline in intake.

Multiple staff interviews confirmed that the resident’s intake had declined significantly when her ability to order outside food was reduced, and that this change was not followed by timely weights, consistent intake documentation, or notification to the provider or dietitian. CNAs reported that the resident disliked facility food, often refused substitutes, and had markedly decreased intake after her food delivery spending was limited; they stated they reported this to nurses, but intake documentation remained sparse or missing for several days. Nursing staff, including an LPN and an RN, acknowledged that when a resident stops eating, a weight should be obtained and the provider and dietitian notified, and that in this case no weight was entered after 1/6/26 despite visible weight loss and very low or refused intakes. The dietary manager and dietitian both stated they were not made aware of the extent of the poor or undocumented intakes, and the resident was not discussed in nutritional risk meetings during the period in question. The DON reviewed the intake records and characterized the charting as completely unacceptable, noting that CNAs are expected to document every meal and that such documentation is essential to monitor whether residents are meeting nutritional needs. The facility’s own weight policy called for a systematic interdisciplinary effort to identify and track residents with significant changes in appetite and decreased oral intake in the last seven days, but this process was not effectively implemented for this resident between 1/6/26 and 1/16/26.