F0692

E

Failure to Implement Dietician Recommendations and Monitor Significant Weight Loss

Gainesville, Florida Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain acceptable nutritional status for two residents experiencing significant weight loss by not following or acting upon dietician assessments and recommendations. For the first resident, who had multiple diagnoses including dementia, hypertension, anemia, type 2 diabetes, hyperlipidemia, hypothyroidism, and vitamin deficiencies, serial weights showed a decline from 106.2 pounds to 93.2 pounds over several months, representing a significant weight loss of over 10%. The registered dietician (RD) documented that the resident was on a regular diet with milkshakes three times daily and Med Pass, with variable intake, and identified a significant 3‑month weight loss likely related to worsening dementia. The RD recommended considering Remeron to stimulate appetite and noted the need to encourage meals, snacks, supplements, and fluids.

Despite these documented recommendations on multiple RD weight notes, the resident’s medical record contained no physician orders for Remeron during the relevant periods. The RD stated in interview that she had recommended Remeron, placed the recommendation in a binder at the nurses’ station, and had spoken with the unit manager and DON, but the recommendation was not conveyed to the physician and was not acknowledged in the communication book. The RD indicated she does not write orders or contact the family or physician, and that this responsibility lies with nursing. An LPN confirmed that nursing did not communicate the RD’s Remeron recommendation or the weight loss to the physician or the resident’s representative, and that staff had incorrectly assumed the RD could write orders.

For the second resident, who had extensive diagnoses including cerebral infarction, peripheral vascular disease, CHF, vascular dementia, mood disorders, insomnia, benign prostatic hyperplasia, neuropathy, and mild protein‑calorie malnutrition, weights showed a decline from 185.4 pounds to 163.1 pounds over six months, a 12.3% loss. A physician order had been written for an in‑house dietician consult for weight loss, and the RD completed a weight note documenting significant 1‑ and 6‑month weight loss, variable intake, and current use of Ensure Plus twice daily. The RD recommended increasing Ensure Plus to three times daily and noted the need to monitor intake, weight trends, and labs. However, there were no additional RD assessments in the record after this note, and the RD acknowledged she had not seen the resident again, was unaware of the continued weight loss, and lacked access to targeted weight‑loss reports. The DON stated there should have been dietary reassessments and that nurses and unit managers should have notified the RD of the continued weight loss, but there was no evidence this occurred, contrary to the facility’s nutritional management policy requiring systematic assessment, individualized interventions, monitoring, and physician notification of significant weight changes.