Failure to implement an ordered dietary supplement for a resident with DM, anorexia, and protein-calorie malnutrition led to missed Glucerna with meals and documented weight loss. The telephone order was not entered on the MAR, dietary instructions were absent, and staff confirmed the supplement was not offered during meal service or medication pass.
Missed Monthly Weights for Residents With Nutritional Concerns: The facility failed to obtain monthly weights for two residents with nutritional diagnoses and care plan monitoring needs. One resident had moderate protein-calorie malnutrition and a physician order for monthly weights, but the record showed a gap in weights with no documented refusal. Another resident with mild protein-calorie malnutrition and a care plan for altered nutritional status also had no monthly weight documented between recorded weights, and the DON confirmed both residents should have been weighed monthly.
A resident with intact cognition and significant weight loss had physician orders and RD recommendations for a house supplement three times daily plus ice cream or pudding with lunch and supper, but staff did not consistently provide them. The dietary card lacked the ice cream or pudding instructions, the MAR showed X’s instead of staff initials, an LPN said she had not been offering the supplement, and the resident reported he only received the items sometimes and was not being offered the supplement.
Ordered Nutritional Supplement Not Provided: A resident with unspecified protein-calorie malnutrition had a physician order for Mighty Shake with lunch and supper, and the care plan directed staff to provide nutritional supplements as ordered. Observations showed the lunch tray did not include the supplement on two occasions, and the ADON, resident, and Dietary Manager all confirmed the supplement was not being placed on the resident’s meal trays.
Failure to provide ordered nutritional supplement with meals. A resident with malignant neoplasm of the brain, colostomy status, and moderate cognitive impairment had a provider order for Mighty Shakes or equivalent with each meal due to potential weight loss/gain and altered nutrition related to the facility ordered diet. Observations of breakfast trays on separate days showed no supplement present, and a CNA confirmed the tray did not include it. The ADON later confirmed the resident should have received the supplement with all meals.
A resident with quadriplegia, severe cognitive impairment, and protein-calorie malnutrition had physician and RD orders for a NAS diet with double meats and a Magic Cup supplement with each meal as part of a comprehensive malnutrition plan. During a survey observation, the breakfast meal ticket showed a Magic Cup was ordered, but the item was missing from the tray. An LPN confirmed the supplement should have been present, the dietary supervisor stated kitchen staff must follow the meal ticket when preparing trays, and the DON acknowledged that ordered dietary supplements are required to be on the tray with meals.
A resident with CKD stage 4, dialysis dependence, and CHF was ordered Nepro three times daily, but a lunch tray was observed without the ordered supplement. The meal ticket showed the supplement was due, and the CNA, LPN, DON, and dietary manager all confirmed it should have been on the tray or obtained from the kitchen.
A resident with severe cognitive impairment, malnutrition, and dysphagia was ordered changed from a mechanical soft diet with ground meats to a regular diet after the resident and RP requested it, but the change was not implemented. Staff continued serving chopped meats, the resident became upset and often refused meals, and the DON confirmed the resident remained on the mechanical soft diet despite the verbal order.
Ordered nutritional supplements were not provided with meal trays for two residents. One resident with dementia, Alzheimer's disease, and abnormal weight loss had orders for a high-protein, high-calorie shake and a Nutri-Freeze cup, but neither item was on the breakfast tray. Another resident with dementia, adult failure to thrive, and abnormal weight loss had orders for a high-protein, high-calorie shake and a Nutri-Freeze cup with meals, but neither item was on the lunch tray. CNAs confirmed the missing items, and the DON stated supplements ordered with meals should be on the tray as ordered.
A resident with cancer, dysphagia, and DM with CKD had a significant 7.11% weight loss after hospitalization, but the facility did not follow its weight loss management policy. Staff did not document timely notification of the RD, MD, or RP, did not hold the required IDT review, did not document weekly weights or monthly follow-up, and no new nutrition interventions were in place when the resident later was recommended sugar free health shakes that were not provided with meals.
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