Failure to Implement Nutritional Interventions for Dependent Resident
Penalty
Summary
The facility failed to initiate nutritional interventions and ensure sufficient food and fluid intake for a cognitively impaired resident who was dependent on staff for feeding. A comprehensive MDS assessment dated September 4, 2025, showed that the resident had swallowing difficulties and required staff assistance with all daily care tasks, including feeding. The resident’s care plan, updated the same day, identified increased nutrition risk and directed staff to offer an alternative meal if the resident consumed less than 50% of a meal and to spoon feed nectar thick liquids. Meal intake records for November 2025 documented that the resident ate less than 50% of multiple meals across numerous days, including several breakfasts, lunches, and dinners. Despite these repeated low intakes, there was no documented evidence that staff offered alternative meals or additional fluids for hydration on the identified dates, as required by the care plan. On November 23, 2025, a nursing note recorded that the resident’s sister expressed concern about the resident’s recent poor intake and lethargy. Later that day, another nursing note documented that the resident was found unresponsive and in respiratory distress and was transferred to the hospital. A subsequent nursing note indicated that the resident was admitted with hyponatremia, a urinary tract infection, and pneumonia. In an interview, the DON confirmed there was no indication that the resident had been offered alternative meals or fluids on the dates of poor intake and acknowledged that this should have occurred.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.