F0692

D

Failure to Implement and Communicate RD-Recommended Nutritional Interventions After Significant Weight Loss

Saint Peters, Missouri Survey Completed on 02-24-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement, evaluate, and modify nutritional interventions to prevent significant weight loss for one resident. The facility’s own policy required a weight change investigation for significant weight changes of 5% or more in one month, 7.5% or more in three months, and/or 10% or more in six months, with subsequent contact of the dietician and physician, updating of interventions, and ongoing monthly investigation until weight stabilized. The resident’s care plan for nutrition and hydration, initiated in early December, identified potential for alterations in nutrition and hydration and directed staff to evaluate weight changes, determine percentage change, follow facility protocol for weight change, and monitor for signs and symptoms of malnutrition. The comprehensive MDS documented severe cognitive impairment, dependence for ADLs, an unstageable pressure ulcer, and increased nutritional needs, but no difficulty swallowing and no nutritional approaches at that time.

The resident was admitted with multiple significant diagnoses including acute respiratory failure, pulmonary edema, CHF, diabetes, protein-calorie malnutrition, osteoporosis, and osteomyelitis of the left ankle and foot. Weights recorded in the EMR showed 192 lbs on 12/06, 185 lbs on 12/11, and 185.2 lbs on 12/13. On 12/16, the RD evaluated the resident, noted a weight of 185.2 lbs and increased nutrient needs related to a large chronic unstageable pressure ulcer to the left heel, and recommended discontinuing certain diet restrictions, changing to a regular no added salt diet with sugar-free beverages and diet condiments, and adding Pro Heal 30 ml BID and Juven BID. The January POS reflected the NAS diet, Juven BID, and ProHealth 30 ml BID, but there were no documented weights from 12/14 through 01/21, and a weight of 159.8 lbs was then recorded on 01/22, representing a 25.4 lb loss since 12/13. The RD’s 01/29 note identified this as a significant weight loss, noted the resident reported not being interested in food, and recommended adding Magic Cup BID at lunch and dinner, to be included as dietary fluids.

Despite this recommendation, the January POS contained no order for Magic Cup, and no weights were documented from 01/22 through 02/22, with the next weight of 163.8 lbs recorded on 02/23. The February POS also showed no order for Magic Cup, and the resident’s nutrition/hydration care plan contained no interventions specifically addressing weight loss. Multiple meal observations on 02/23 and 02/24 showed the resident receiving meals without Magic Cup, and both the resident and a family member reported that Magic Cups had not been provided. The RD stated that recommendations were emailed to the Administrator, DON, DM, and Care Plan Coordinator, that she had noted significant weight loss and recommended Magic Cup BID, and that she did not know why these recommendations were not communicated to the physician. The DM acknowledged receiving RD emails and changing diet cards based on recommendations, but stated the resident did not have Magic Cup in the diet order and that he must have missed that RD recommendation. The Interim DON, Administrator, and Medical Director each stated they would expect RD recommendations to be reviewed and communicated to the physician for residents with weight loss, but this did not occur, and the facility failed to implement and integrate the RD’s recommended intervention for Magic Cup or to update the care plan with weight-loss interventions while the resident experienced a 13.98% weight loss in two months.

Additionally, the facility did not consistently obtain and document weights per its policy and the resident’s care plan. There were gaps in weight documentation between mid-December and late January, and again from late January to late February, despite the resident’s known risk factors, existing pressure ulcer, and documented significant weight loss. The RD reported having noted weight discrepancies that had not been addressed. The MDS also showed that dental status was not assessed. Collectively, these inactions—failure to consistently monitor weights, failure to initiate and document weight change investigations as required by policy, failure to communicate and obtain physician orders for RD-recommended interventions, and failure to update the care plan with specific weight-loss interventions—led to the resident’s unaddressed significant weight loss.

The facility’s own staff interviews confirmed that the process for handling RD recommendations was not effectively carried out. The LPN reported not seeing any Magic Cup recommendations in the resident’s record. The RD described a practice of emailing recommendations but not participating in IDT meetings, and acknowledged that her recommendation for Magic Cup BID was not communicated to the physician. The DM confirmed that he relies on RD emails to change diet cards and admitted that he must have missed the Magic Cup recommendation, resulting in no diet order for Magic Cup. Leadership staff, including the Interim DON, Administrator, and Medical Director, each stated expectations that RD recommendations be reviewed and communicated to the physician for residents with weight loss, but these expectations were not met in this case, contributing to the failure to implement appropriate nutritional interventions for the resident experiencing significant weight loss.