F0656

D

Failure to Update Care Plan for Significant Weight Loss in Tube-Fed Resident

Stillwater, Oklahoma Survey Completed on 02-10-2026

Penalty

No penalty information released

Summary

The facility failed to update and implement a comprehensive care plan to address significant weight loss for one resident who received nutrition via a feeding tube. Record review showed the resident weighed 213.6 pounds on 12/24/25 and 198.4 pounds on 01/19/26, an 8.66% loss between 12/24/25 and 01/23/26, yet the existing care plan dated 12/29/25 only reflected that the resident required tube feeding and included an intervention for the registered dietitian to evaluate quarterly and as needed, with no update documenting the significant weight loss or additional interventions. A physician’s order dated 01/17/26 directed bolus feedings of Jevity 1.5 five times daily, and the admission MDS documented diagnoses including malnutrition, gastrointestinal hemorrhage, and dysphagia, with tube feeding required and no prior 5% or greater weight loss in the last month. During interview, an LPN stated the resident was placed on five bolus feedings daily for a few days, and the MDS coordinator, after reviewing the weight summary, acknowledged the care plan should have reflected the resident’s greater than 5% monthly weight loss and included interventions to prevent further weight loss.

This deficiency involved the facility’s inaction in revising the care plan despite documented significant weight loss and existing clinical information indicating the resident’s nutritional risk, as well as reliance on assessments for weight information without ensuring that the care plan was updated to address the change in condition.