F0692

E

Failure to Implement and Coordinate Nutritional Interventions for Significant Weight Loss

Odessa, Texas Survey Completed on 02-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident maintained acceptable parameters of nutritional status, as evidenced by an 11.47% weight loss over 80 days without timely and fully implemented interventions. The resident was an elderly female admitted with diagnoses including protein-calorie malnutrition, diabetes mellitus, dementia, and anxiety disorder. Her admission MDS showed severe cognitive impairment (BIMS score of 2), a regular diet, and no documented weight loss or physician-ordered weight-loss program. Her care plan, revised in early December, identified her as at risk for malnutrition with interventions such as determining food preferences, monitoring and documenting intake, monitoring weight per facility protocol, serving the ordered diet, and notifying the physician of negative findings.

Weight records showed an active decline from early December through mid-February, with the resident’s weight decreasing from 191.8 pounds to 169.8 pounds. A nutrition assessment by the RD in mid-December documented a weight of 185.6 pounds, a regular diet and texture, and food intake ranging from 25–100%. A weight watchers’ assessment in mid-January identified a 14.4‑pound weight loss and listed interventions of a red glass and a 2‑calorie supplement with each med pass. However, the resident did not appear on the facility’s red cup program list, and there were no corresponding physician orders in January for supplements or the red glass program. In February, no supplement order was present until mid-month, when Boost twice daily was ordered; there was still no physician order for the red glass program.

Observations and interviews further demonstrated that the identified interventions were not consistently implemented or communicated. During lunch observations on consecutive days in February, the resident took only a few bites of food, repeatedly left the table, and on one day accepted a supplement, while on another day no alternative or supplement was observed being offered. The Dietary Manager stated she was responsible for the red glass program notifications but was unaware of the resident’s weight loss and confirmed the resident was not on the snack list. The new DON reported she had only recently become aware of the weight loss, implemented a supplement order mid-February, and believed the resident should have had weekly weights, supplements, and placement on the red glass program. The ADON acknowledged completing a weight watcher assessment in mid-January and intending to initiate the red glass program and 2‑calorie supplements with each med pass but admitted she forgot to enter these as physician orders. The RD stated she had recommended house supplements three times daily on admission and that these should have been entered as physician orders, but the resident did not appear on the January weight loss report. The NP reported she was unaware of the extent of the weight loss and had not been notified. These actions and inactions occurred despite a facility policy requiring review of significant weight changes, documentation on weight watcher forms with interventions, physician and family notification, initiation of an acute care plan for weight loss, and RD assessment and recommendations for significant weight loss.

The facility’s own policy defined significant weight loss thresholds and required that such changes be recorded on a weight watchers’ form with interventions and follow-up, that the physician and family be notified, and that an acute care plan for weight loss be initiated. It also required referral of all significant weight changes to the Regional Dietitian for assessment and review of interventions. In this case, although a weight watchers’ assessment was completed and interventions were listed, they were not converted into active physician orders, the resident was not placed on the red glass program list, and the RD did not receive accurate weight loss reporting in January. Staff interviews showed inconsistent awareness of the resident’s weight loss and program status, and the NP was not informed of the significant weight change. These documented failures to follow policy and to implement and coordinate ordered or recommended nutritional interventions contributed directly to the resident’s continued weight decline.

Throughout this period, meal intake documentation for January and February continued to show 25–100% consumption, while direct observations showed poor intake and difficulty remaining at the table. CNAs and nursing staff reported offering alternatives and snacks generally, but the assigned CNA confirmed the resident was not on the red cup program, which was supposed to trigger extra attention to intake. The DON, ADON, RD, and NP each described gaps in communication and follow-through regarding weight monitoring, program placement, and supplement orders. Collectively, these documented lapses in monitoring, communication, and implementation of nutritional interventions led to the resident’s significant, ongoing weight loss and constituted the cited deficiency in maintaining acceptable nutritional status.