F0692

D

Failure to Follow RD Weight Monitoring Recommendations and Implement Total Meal Assistance

Roanoke, Virginia Survey Completed on 03-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain acceptable nutrition and hydration status for one resident by not consistently following RD recommendations for weekly weights and not providing meal assistance as outlined in the comprehensive care plan. The resident had multiple diagnoses including dementia, dysphagia, COPD, diabetes, protein-calorie malnutrition, CHF, chronic kidney disease, and GERD, and was care planned as being at risk for weight loss or malnutrition with significant weight fluctuations. The RD documented significant weight loss on multiple occasions and recommended increased nutritional supplements and weekly weights for four weeks in September, October, and December 2025. However, the clinical record lacked weekly weights for the second week of September, the third week of October, and the second week of December, and the DON was unable to provide documentation for the missing September and October weights, despite a facility policy assigning responsibility to nursing for ensuring and recording timely weights.

The RD’s notes showed ongoing significant weight changes: a weight of 123 lbs on 9/5/25 with a 5% loss in 30 days and 7.5% in 90 days, followed by 116 lbs on 10/4/25 with 5% loss in 30 days, 7.5% in 90 days, and 10% in 180 days. Later, a weight of 128.5 lbs on 11/7/25 reflected a documented rebound gain, and by 12/5/25 the weight had decreased again to 121 lbs with a 5% loss in 30 days and 10% in 180 days, and then to 119 lbs on 12/26/25. The RD repeatedly recommended weekly weights for monitoring during these periods of significant loss, and the facility’s own policy required a system to weigh, monitor, and track weights, with the DON responsible for ensuring patients are weighed in an acceptable time frame. Despite this, the missing weekly weights in September and October were not supported by refusal documentation or other explanation.

The facility also failed to consistently implement the care-planned intervention of total assistance with meals when the resident’s condition declined. The care plan, revised in December 2025, included interventions such as encouragement to eat, recording meal intake percentages, providing supplements as ordered, total assist for meals, and weights as ordered. However, CNA documentation for December 2025 showed the resident as requiring only set-up assistance or being independent for all meals except one evening meal, despite interviews indicating that toward the end of the resident’s stay staff had to feed the resident and that the resident became dependent for eating and drinking. Multiple CNAs and nursing staff reported that the resident transitioned from supervision/set-up to needing to be fed and that the resident was on a “feed list,” with some staff stating this dependence had been present for at least weeks to months before hospital transfer, while CNA documentation continued to reflect primarily set-up or independent status. This discrepancy between documented assistance levels and staff interviews, along with the missing weekly weights despite RD recommendations, formed the basis of the identified deficiency in maintaining the resident’s nutrition and hydration status.

Interviews with the PA and nursing staff further described the resident’s decline and concerns about hydration. The PA reported that the resident experienced a decline in condition and was treated in the facility with IV fluids, labs, and antibiotics for a UTI, and later became profoundly dehydrated, prompting transfer to the hospital. The PA and nursing staff stated that the resident was on the list to be fed and that staff were feeding and offering fluids, but the PA acknowledged never being present in the room at mealtimes. CNAs and nurses described a rapid decline in the resident’s ability to eat and drink, including needing staff to hold cups, becoming total assist for meals, and sometimes refusing to open her mouth or swallow. Despite these descriptions, the December CNA documentation largely reflected only set-up or independent meal status, and the facility could not fully substantiate adherence to RD-directed weekly weight monitoring during periods of significant weight loss.

The DON stated that the resident sometimes refused care, including being weighed, and produced documentation of a refusal for a December weekly weight but could not locate documentation for the missing September and October weights. The facility’s weight monitoring policy specified that weights are to be tracked, monitored, and analyzed by the IDT, and that nursing staff are responsible for recording weights in the clinical record. The lack of documented weekly weights as recommended by the RD, combined with inconsistent documentation of the resident’s need for total assistance with meals compared to staff interviews and the care plan, demonstrated that the facility did not fully implement and document the interventions necessary to maintain the resident’s nutritional and hydration status as required.