F0692

E

Failure to Complete Required Nutrition Assessments per Facility Policy

Petersburg, West Virginia Survey Completed on 02-11-2026

Penalty

No penalty information released

Summary

The facility failed to ensure nutrition assessments were completed per its Medical Nutrition Therapy: Assessment and Care Planning policy, which requires nutrition status to be assessed upon admission and monitored at least quarterly, with comprehensive assessments annually, upon referral, or as indicated by clinical condition. The policy assigns responsibility for completion of nutrition assessments, including MDS and care area assessments, to the RDN or other qualified nutrition professional within 14 days of admission and at least annually, and allows delegation of assessment-related tasks to other qualified dietary staff. Record review showed that these required assessments were not consistently completed within the required time frames for multiple residents.

For one resident admitted in early June 2023, the record showed an admission assessment and multiple quarterly and annual assessments; however, there were no annual assessments completed around June 2024 and June 2025 within a 30‑day window of the anniversary dates, contrary to policy. Another resident admitted in early December 2024 had an admission assessment, quarterly assessments, and weight-change assessments documented, but no annual assessment was completed around the December 2025 anniversary date within a 30‑day window. A third resident admitted in late August 2022 had an admission assessment, annual assessments, quarterly assessments, and weight-change documentation, but no annual assessment was completed around the August 2025 anniversary date within a 30‑day window.

A fourth resident experienced an 11.1% weight loss over six months, with weight decreasing from 326 lbs to 289.8 lbs, and had multiple diagnoses including morbid obesity due to excess calories, type 2 DM with neuropathy, anemia in chronic disease, B‑vitamin deficiency, vitamin D deficiency, HTN, and GERD. The resident’s care plan noted a desire to lose weight and return home, resistance to therapy, and nonadherence to diet, with an intervention for dietary consult PRN. The record showed quarterly nutrition assessments on three dates in 2024–2025 and an annual assessment in late December 2025, but no quarterly assessments after June 2025 and no dietician progress notes between early September 2025 and early February 2026. In interviews, the Dietary Supervisor stated that the dietician completes all assessments and that she did not assist because she believed she was not qualified, and she was unaware the policy allowed delegation. The dietician reported that she generally completes admission and annual assessments and only sometimes completes quarterly assessments, sometimes documenting in progress notes instead, and had no explanation when informed that no assessments were documented for the resident with significant weight loss after June 2025.