F0656

D

Failure to Follow Care Plan for Total Meal Assistance

Roanoke, Virginia Survey Completed on 03-11-2026

Penalty

No penalty information released

Summary

Facility staff failed to follow a comprehensive person-centered care plan for a resident who was care planned to receive total assistance with meals. The resident had multiple diagnoses including dementia, dysphagia, COPD, diabetes, protein-calorie malnutrition, congestive heart disease, chronic kidney disease, and GERD. The comprehensive care plan, initiated in late 2022 and revised in late 2025, identified the resident as being at risk for weight loss or malnutrition related to chronic disease and cognitive impairment, and included interventions such as encouragement to eat, recording meal intake, supplements as ordered, weights as ordered, and total assist for meals (revised 12/7/25). Despite this, the annual MDS assessment dated 11/19/25 documented the resident as requiring only set up or clean up assistance with meals and being able to feed self during the lookback period, and also noted a significant unplanned weight gain.

Review of CNA documentation for December 2025 showed that the resident was consistently documented as needing only set up assistance (code 05) or being independent (code 06) for meals on all days except one evening meal, when the resident was documented as dependent. Across 93 meals in December, the resident’s intake was recorded mostly in the higher percentage ranges, with some meals at lower intake and two refusals. In January 2026, prior to the resident’s transfer to the hospital on 1/9/26, documentation reflected variable levels of assistance: independent for some shifts, set up or clean up assist for others, supervision for two shifts, and dependent for six shifts, with one refusal. Meal intake percentages in January ranged from 76–100% for most meals to 0–25% for several meals.

Interviews with CNAs and the Unit Manager revealed that direct care staff relied on a unit “feed list” rather than the resident’s care plan to determine whether to feed the resident or provide only set up/supervision. CNA #1 and CNA #2 described the resident as initially independent or requiring supervision with meals, with staff setting up trays and checking back, and only later providing full feeding assistance as the resident’s condition declined. CNA #2 and CNA #3 both stated they did not know what the care plan said about feeding and followed the list instead. The Unit Manager confirmed the existence of a list indicating which residents should be fed (names in bold) versus set up and supervised, and believed the resident’s name was in bold at some point, but could not recall the timeframe. These interviews and documentation demonstrated that staff actions did not consistently align with the care-planned intervention of total assist for meals.