F0692

D

Failure to Reassess and Adjust Nutritional Care for Malnourished Resident With Pressure Injuries

Hatboro, Pennsylvania Survey Completed on 03-17-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that a resident maintained acceptable nutritional status and usual or desirable body weight, despite existing policies requiring comprehensive nutritional assessment and monitoring. The facility’s nutritional assessment policy from 2001 assigned responsibility to the physician, dietitian, and nursing staff, and required a nutritional assessment with any change in condition, including identification of usual intake, appetite, meal patterns, and clinical conditions affecting nutrition. For this resident, a quarterly MDS dated October 11, 2025 documented diagnoses of urinary tract infection and malnutrition, a height of 66 inches, weight of 130 pounds, and a physician-prescribed weight gain regimen. A subsequent quarterly assessment showed the resident still had malnutrition, a pressure ulcer, the same height, and a reduced weight of 122 pounds, with intake of 25% or less of total calories provided.

A wound care assessment documented development of a right lateral ankle deep tissue injury, and the physician ordered daily wound care and a nutritional supplement of liquid protein on January 27, 2026. A later wound consultant assessment identified a Stage IV pressure injury on the right lateral calf with exposed tendon and an unstageable wound on the right lateral ankle, with specific wound treatments ordered. The DON confirmed these wound findings. The registered dietitian’s evaluation on October 8, 2025 recorded the resident’s ideal body weight as 142 pounds and actual weight as 129.6 pounds, with a care plan goal for weight gain to ideal body weight. A dietitian progress note on November 6, 2025 documented a significant weight loss to 122 pounds. On December 31, 2025, the dietitian clarified that the resident’s weight was 122 pounds, not 215.8 pounds as nursing staff had documented, and the DON later confirmed the 122‑pound weight on that date and again on February 26, 2026.

Meal and snack intake records showed poor evening meal consumption of food and fluids on 12 of 28 days in February 2026 and poor evening snack consumption on 21 of 28 days that month, which the DON confirmed. For March 1 through March 4, 2026, the clinical record showed poor intake at meals and evening snacks, including poor breakfast and dinner intake on one day, no documented intake at the noon meal on another day, and poor dinner intake on a subsequent day, all confirmed by the DON. Despite the diagnosis of malnutrition, lack of weight gain, and documented poor intake over February and early March, there was no documentation that the registered dietitian completed a nutritional assessment for those months, and no nutritional care plan changes or updates were made; the resident remained on a regular pureed diet with a house shake 4 oz twice daily and protein liquid twice daily. The administrator confirmed the lack of documented assessment, monitoring, and nutrition care plan revision. Hospital records later showed the resident was admitted with osteomyelitis of the right leg involving the tibia, fibula, and ankle.