F0656

D

Failure to Implement Nutrition Care Plan and Diet Modifications

Shelton, Washington Survey Completed on 02-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement care plan interventions for low meal intake and diet modifications for a resident with severe cognitive impairment, paraplegia/functional quadriplegia, dementia, and cancer. The resident’s MDS showed dependence on staff for eating, transfers, and bed mobility. A nutrition care plan dated 12/16/2025 identified the resident as at risk for nutritional problems related to a new environment, altered diet, poor appetite, and varied intake, with interventions to monitor and document circumstances around mealtimes and refusals, determine patterns or causes of low intake, alter or remove causes when possible, and monitor and report situations leading to decreased food consumption. Despite this, review of the medical record showed no documentation that staff attempted to determine circumstances, patterns, or causes of the resident’s limited meal intake.

Meal intake records from mid- to late December showed the resident repeatedly consumed only 0–25% of multiple meals across many days, while a progress note on 12/23/2025 documented that the resident was on alert for low meal intake, triggering for skin conditions, low intake, and low fluid intake, with weight decreased from 201 to 195 pounds. The note indicated staff would encourage oral intake, assist with meals, and monitor weights, but there was no evidence that the specific care plan interventions to analyze mealtime circumstances and causes of poor intake were carried out. A speech therapy note on 12/23/2025 documented that the resident tolerated mildly thick (MT2) liquids better than thin liquids, that nursing staff were instructed on the diet change, and that no thin liquids should be accessible during meals. Corresponding physician orders and care plan updates specified a minced and moist diet with mildly thick liquids, no straws, upright positioning, and 1:1 assistance for oral intake.

Despite these orders and care plan interventions, interviews and record review showed that staff did not consistently follow the diet modification and feeding instructions. The medical provider note on 12/24/2025 stated that all thin liquids had not been removed from the resident’s tray after the change to thickened liquids. The resident’s family brought Ensure from home, which staff poured directly into a sippy cup without thickening, and staff reported that the resident sometimes used a straw with this cup, contrary to the no-straw order. The RD acknowledged knowing about home snacks and Ensure but did not request staff to document or track what the resident consumed from these items and did not know what was in the resident’s sippy cup. CNAs and an LPN confirmed that they poured the family-provided supplement into the sippy cup, sometimes with a straw, and that the resident was dependent for eating and sometimes did not go to the dining room, with limited aides making it hard to provide the needed assistance. The DON stated that Ensure straight from the container is not mildly thick, that the resident required 1:1 assistance and no straws per the care plan, and that staff were expected to follow the care plan interventions.