F0692

E

Failure to Implement RD Nutrition Recommendations for Multiple Residents

Bonham, Texas Survey Completed on 02-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure residents maintained acceptable nutritional status by not implementing or acting upon registered dietician (RD) recommendations for four residents. For the first resident, who had celiac disease and cystic fibrosis with intestinal manifestations, the RD documented a recommendation for ice cream twice daily with lunch and dinner to address nutritional needs. The electronic medical record (EMR) contained no corresponding physician order, and there was no documentation that the physician had been notified to accept or decline the recommendation. The resident’s care plan referenced RD evaluation and diet change recommendations as needed, but the diet order remained unchanged since its original entry, and the resident reported never receiving ice cream with meals. Observation of a lunch meal confirmed that ice cream was not provided and was not listed on the tray ticket.

For the second resident, who had COPD, hypertension, diabetes type II, heart failure, and obesity, the RD recommended a sugar-free health shake once daily between meals. The EMR showed no order for the health shake and no documentation that the physician had been contacted regarding the recommendation. The resident’s care plan included interventions for providing diet as ordered and RD evaluation as needed, but the diet order had not been updated since its original date. The resident stated he had not received a health shake between meals and did not recall ever receiving one. Weight records showed a significant weight loss over a one‑month period, and there was no evidence that the RD’s recommendation had been translated into an active order or implemented.

For the third resident, who had peripheral vascular disease, a chronic left foot ulcer, protein‑calorie malnutrition, anemia, and hypertension, the RD recommended ice cream with lunch and Prostat 30 cc twice daily for low albumin. The physician’s orders did not include ice cream with lunch or Prostat, and there was no documentation that the physician had been notified to accept or decline these recommendations. The care plan referenced a regular diet with house shake once daily, med pass twice daily, fortified cereal, and providing supplements as recommended or ordered, but the new RD recommendations were not reflected in the orders. The resident reported not receiving ice cream with lunch or a protein drink twice daily, and observation of a lunch meal confirmed that ice cream was not provided and not listed on the diet ticket.

For the fourth resident, who had metabolic encephalopathy, cerebral infarction, Parkinsonism, dysphagia, and a feeding tube, the RD recommended Med Pass 2.0, 120 cc twice daily, to prevent further weight loss. The physician’s orders did not include Med Pass 2.0 twice daily, and the care plan focused on tube feeding with Jevity 1.5 and pleasure feedings, along with RD evaluation and monitoring of caloric intake. Nursing staff confirmed there was no order for Med Pass 2.0 twice daily. Interviews with the Food Service Supervisor indicated that dietary recommendations were to be provided to the DON for physician review and that nursing was responsible for entering orders into the EMR and notifying dietary so changes could be added to tray tickets; the supervisor reported not receiving any January recommendations for these four residents. The RD stated she provided recommendations within 24 hours of her visit and expected them to be acted upon with the physician within 72 hours, consistent with facility policy, but the physician later confirmed he had not been notified of the RD’s recommendations for these residents. The DON and ADON acknowledged that the recommendations had been assigned for follow‑up but were not completed, and the DON stated it was her responsibility to ensure timely physician notification, in accordance with the facility’s policy requiring consultant recommendations to be followed up within 72 hours and non‑accepted recommendations to be documented in the nurse’s notes and on the recommendation sheet.