F0656

D

Failure to Care Plan Dialysis-Related Nutritional Needs

Lancaster, California Survey Completed on 03-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and implement a person-centered care plan addressing a resident’s nutritional needs in relation to an early hemodialysis schedule. The resident was admitted with diagnoses including metabolic encephalopathy, diabetes mellitus, and end stage renal disease requiring renal dialysis. The care plan dated 2/25/2026 documented that the resident was dependent on staff for eating and included a hemodialysis care plan that only indicated dietary consultation for meal planning as indicated. A separate care plan dated 2/26/2026 identified risk of malnutrition with interventions such as allowing adequate time for meal consumption, assisting with meals and fluids as needed, monitoring meal intake, and providing diet as ordered, and an order for feeding assistance was in place.

On 2/27/2026, the resident’s dialysis schedule required pickup from the SNF at 8:00 a.m. for an 8:45 a.m. treatment, as documented on the Order Recapitulation Report. The Pre-Hemodialysis Communication Observation/Assessment for that date showed the resident was picked up at 7:50 a.m., but the section for time of last meal was left blank. Progress notes from 8:30 a.m. the same day indicated that transportation had picked up the resident before she had eaten breakfast. The notes further indicated that the Dietary Supervisor was informed and a sack lunch was prepared and sent to the dialysis center, but this occurred after the resident had already left the facility.

During interviews, the Dietary Supervisor confirmed that the resident was picked up for dialysis without a sack lunch and that the meal sent later was delayed. In a concurrent interview and record review, the ADON acknowledged that there was no care plan developed to address the resident’s breakfast intake in relation to the early dialysis schedule and that the existing malnutrition interventions (allowing adequate time for meals, assisting with meals/fluids, and providing diet as ordered) were not implemented. The ADON stated the resident should have been fed by the outgoing shift before pickup and should have had a sack lunch to take to dialysis, and noted that without breakfast and a sack lunch the resident could have developed hypoglycemia. The facility’s Nutritional Assessment and Care Planning policy required that nutritional assessments be used to develop individualized care plans addressing causes of impaired nutrition, resident preferences, goals, benchmarks, and time frames, but this was not done for the resident’s dialysis-related nutritional needs.