F0692

G

Failure to Provide Ordered Vegetarian Diet, Address Significant Weight Loss, and Serve Breakfast on Dialysis Days

El Dorado, Kansas Survey Completed on 04-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to meet residents’ nutritional needs by not honoring a prescribed vegetarian diet and not responding to significant weight loss for one resident, and by not providing breakfast meals on dialysis days for another resident. One resident with diabetes mellitus was admitted for IV antibiotic therapy after a recent UTI and was identified as at risk for dehydration and nutritional issues. Her baseline care plan and physician orders documented a vegetarian diet, regular texture, and thin liquids, and the care plan instructed staff to monitor and record meal intakes, obtain RD evaluation as needed, and complete weekly weights. Despite this, her MDS showed she did not receive a therapeutic diet, and her meal tickets were printed as a regular diet with meat-based options such as chicken, cheeseburger, hot dog, and sloppy joe, and no vegetarian menu was available. Dietary staff acknowledged they did not have a vegetarian meal ticket for her and had not yet ordered soy burgers, and staff reported difficulty providing her vegetarian diet due to lack of appropriate choices.

The same resident’s intake of facility-provided meals was documented as poor, less than 50% of meals, and she was described as very particular about what she ate, with her husband frequently bringing in outside food of unknown amounts. Weights documented in the EMR showed 156.2 lbs on admission and again on a later date, followed by a drop to 132.8 lbs and then a calculated weight of 128.4 lbs when the wheelchair weight was subtracted, representing a significant weight loss of 16.3% in 19 days. The EMR lacked a progress note addressing the weight loss on the date it was first recorded, and nursing documentation showed that when the provider was in the facility shortly after the low weight was obtained, staff updated the provider about low blood pressure but not about the weight loss. The provider was not documented as being notified of the weight loss until several days later, and there was no evidence of re-weighing, appetite stimulant orders, or nutritional supplements being initiated despite existing orders allowing the RD or interdisciplinary team to start supplements. Administrative and dietary staff later reported they were unaware of the weight loss at the time and had not reviewed the resident’s weights.

The deficiency also includes failure to provide breakfast meals to another resident with ESRD and moderate protein-calorie malnutrition who received dialysis three times per week. This resident had a therapeutic renal dialysis diet ordered and required set-up assistance for eating, with documentation that his meal intakes were generally good and adequate to meet estimated needs. His EMR showed multiple breakfast meal entries on dialysis days marked as “not available” or “not applicable,” and staff interviews revealed that he left very early for dialysis and was not provided breakfast or a snack to take with him. The resident reported he did not eat breakfast before dialysis because none was provided, and he did not receive a snack at the dialysis center. CNAs and an LN confirmed that no actual breakfast meal was prepared for him on dialysis mornings, the kitchen was closed at the time he woke up, and no alternative food or drinks were offered to take with him. The facility’s own policies on dialysis care and frequency of meals required communication about nutritional management and provision of at least three meals daily at regular times or according to resident needs and care plan, but these were not followed for this resident on dialysis days.

The facility’s Nutrition (Impaired)/Unplanned Weight Loss clinical protocol required monitoring and documenting weight and dietary intake in a way that allowed ready comparison over time, defining current nutritional status through interdisciplinary assessment, and using supplementation strategies such as food fortification and increased portions for residents with impaired nutrition or risk factors. For the resident with significant weight loss and a vegetarian diet order, the record and interviews showed that although poor intake and vegetarian preference were known, the facility did not adjust menus to provide appropriate vegetarian options, did not consistently document or act on poor intake, and did not promptly assess or intervene when substantial weight loss occurred. For the resident on dialysis, the facility’s Dialysis, Care for a Resident policy required communication about nutritional and fluid management, and the Frequency of Meals policy required at least three meals or their equivalent daily, but staff acknowledged that no breakfast meal or equivalent was prepared or offered on dialysis mornings, and refusals were not documented in the EMR or care plan.