F0692

D

Failure to Provide Ordered Nutritional Supplements to Resident With Significant Weight Loss

Oklahoma City, Oklahoma Survey Completed on 02-18-2026

Penalty

Fine: $50,116

Summary

The deficiency involves the facility’s failure to provide ordered nutritional supplements and to follow the resident’s care plan interventions to prevent avoidable weight loss. A resident with protein-calorie malnutrition had a care plan dated 10/10/25 directing staff to offer a meal replacement supplement whenever 50% or less of a meal was consumed. The resident’s weight log showed a decline from 170 pounds on 12/05/25 to 158.5 pounds on 01/05/26, and further to 155 pounds on 02/04/26. A dietician’s note dated 01/20/26 documented significant weight loss of 8.8% in one month and 15.3% in six months, with meal intake ranging from 25–50% of meals. The dietician recommended health shakes three times daily with meals, but there was no documentation that these health shakes were provided on multiple consecutive days.

During observation on 02/11/26 at 9:16 a.m., the resident was seen lying in bed with eyes closed and an untouched breakfast tray on their walker seat. The resident’s admission assessment dated 12/20/25 showed diagnoses including pancytopenia, renal insufficiency, and cirrhosis of the liver, and a BIMS score of 12 indicating moderate cognitive impairment. On interview, the resident stated they did not receive any meal supplements and expressed that they liked them but did not know why they were no longer provided. CNA #2 confirmed the resident did not receive health shakes or additional supplements when consuming 50% or less of meals, noting the resident never ate much and had little appetite. The DON later stated the resident should have been receiving health shakes when 50% or less of meals were consumed, confirming that the ordered nutritional interventions were not implemented.