F0692

D

Failure to Implement RD-Recommended Nutritional Supplement for Resident With Significant Weight Loss

Rutherfordton, North Carolina Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement and maintain physician-ordered nutritional supplements in accordance with RD recommendations for a resident with significant weight loss. The resident was admitted with Alzheimer’s disease and had a care plan identifying potential nutritional problems related to a mechanically altered and therapeutic diet, with interventions including RD evaluation and diet changes as needed. The resident’s weight declined from an admission weight of 206 lbs to 185 lbs, with an RD note documenting a 7.8% weight loss in 30 days and recommending fortified foods. A physician subsequently ordered a fortified nutritional shake 120 ml twice daily for weight loss, and the resident’s weight later increased to 186 lbs before the fortified shake was discontinued.

Following discontinuation of the fortified shake, the resident’s weight continued to decline, with documented weights of 171 lbs, 173.5 lbs, 168.5 lbs, and 161.5 lbs over subsequent months. RD notes on multiple dates (12/1, 12/8, 1/16, and 2/12) documented ongoing significant weight loss over 30, 90, and 180 days, BMIs in the obese range, and repeatedly indicated that the resident was receiving a fortified nutritional shake 120 ml twice daily, with recommendations to reweigh, monitor, continue the plan of care, and later increase the shake to 120 ml three times daily. However, review of the MARs for December, January, and February showed no active orders for the fortified nutritional shake, either twice or three times daily, despite these RD notes and a progress note from a risk meeting directing continuation and later increase of the supplement.

Interviews with nursing staff, the RD, unit coordinator, nurse supervisor, DON, NP, and administrator revealed that floor nurses relied on the MAR to administer supplements and did not see an active order for the fortified shake. Staff reported that supplement orders were generally expected to be entered by the RD, DON, or unit coordinators based on risk meeting discussions and RD recommendations, but no one verified that the orders were actually entered or active. The RD acknowledged that the fortified shake should have been restarted in December and increased in February per her recommendations and that she did not know why the orders were not entered. The DON and unit leadership described a process in which RD recommendations were read aloud and progress notes were written, but they did not confirm that corresponding orders were in place. As a result, the resident did not receive the ordered fortified nutritional shake despite documented significant weight loss and repeated RD recommendations and risk meeting notes indicating that the supplement was or should be in use.