Failure to Implement Nutritional Interventions and Provide Ordered Double Portions
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow nutritional interventions for a resident with known significant weight loss, and failure to provide ordered double portions for multiple residents. One resident’s care plan, initiated on 11/03/2025, identified risk for compromised nutritional status with a goal of preventing further weight loss and an intervention to serve the ordered nutritional diet. Despite this, observations on 12/09/2025 showed the resident, who appeared thin and frail, was served only single portions of turkey, mashed potatoes, and mixed vegetables, even though the meal ticket specified double portions. The facility also failed to consistently document the resident’s meal intake, with the EMR showing only fifteen meal intake entries in the prior 30 days and the last recorded meal on 11/30/2025. On 12/10/2025, the same resident was observed sleeping in the dining room during lunch and was not served a meal during the meal service; staff stated they would later offer two peanut butter and jelly sandwiches and were unsure if the resident had eaten breakfast. The EMR confirmed no meal intake documentation after 11/30/2025. A standing weight obtained on 12/11/2025 was 131.8 lbs, compared with prior recorded weights of 159.2 lbs on 09/05/2025, 138.0 lbs on 10/14/2025, 147.0 lbs on 11/04/2025, and 145.7 lbs on 12/05/2025. The registered dietitian documented that the resident had a history of weight loss, significant weight loss over three and six months, and a BMI of 19.9, and noted that the resident was receiving a 240 ml nutritional supplement three times daily with no new recommendations. The dietitian later stated she suspected an error in the November weight, was aware of the family’s request for double portions, and was very concerned about the additional 10.3% weight loss in one month, indicating that closer monitoring of weights and intake might have prevented the significant weight loss. The facility also failed to serve ordered double portions for two additional residents reviewed for nutrition.
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