Incorrect Enteral Feeding Formula Administered: A resident with a G-tube, supraglottic cancer, and severe protein malnutrition was ordered Jevity 1.5 CAL 240 ml five times daily, but an LPN administered Jevity 1.2 CAL instead. The nurse confirmed the wrong formula was given because only Jevity 1.2 CAL was available on the unit, and the RD stated the formula was not clinically appropriate for the resident’s nutritional needs.
Fluid restrictions not followed or accurately documented for two residents. Two cognitively intact residents with ESRD and dialysis had strict fluid restriction orders, but meal tickets did not show the restrictions and staff provided or observed fluids beyond the ordered amounts. CNA and nursing staff said they relied on meal tickets, documented only what they personally gave, and did not consistently account for fluids given with meals, medications, or other sources. The RD and DON acknowledged that the ordered fluid amounts were not being consistently tracked across dietary and nursing.
Failure to Timely Identify Significant Weight Loss: A resident with severe cognitive impairment, DM2, and nutritional risk had a clinically significant 9.7% weight loss that was not timely identified or reviewed. The record did not show a Dietitian assessment after the loss, and staff interviews indicated the weight discrepancy was not promptly reweighed or escalated to the nurse, Dietitian, physician, or DON as expected.
Failure to address significant weight loss: A resident with dementia, FTT, and schizoaffective disorder had a marked decline in weight while refusing meals and stating the food was poisoned. Although staff and the NP were aware of the loss, the record did not show an RD referral, a completed nutritional assessment, or added nutritional interventions such as supplements or other diet changes.
Failure to Address Significant Weight Loss and Weight Gain: The facility did not implement adequate nutritional interventions for two residents with significant wt loss and one resident with significant wt gain. One resident with Parkinson’s disease and dysphagia had a 12.4% wt loss without follow-up nutrition assessments or documented interventions, and another resident with ESRD on HD had progressive wt loss despite renal diet orders, supplements, and frequent poor intake, nausea/vomiting, and fluid shifts. A cognitively intact resident with CHF gained substantial wt, requested regular portions to lose wt, and continued to receive large portions despite RD recommendations to discontinue them.
Failure to provide ordered nutritional supplements led to significant weight loss for a resident with TBI, dementia, and cerebrovascular disease. After hospital re-admission, the resident was supposed to receive frozen nutritional treats with meals and an Ensure-type supplement for weight stability, but survey observations found the meal-tray supplement missing and staff interviews confirmed the dietary slip did not list it. The RDODS said the dietary department mistakenly stopped sending the supplements, nurses signed the MAR as if they had been given, and the resident’s weight dropped from 151.5 lbs. to 140.3 lbs. over two months.
A deficiency was cited for not providing enough food and fluids to maintain a resident's health, as required. The report indicates that the facility did not meet the necessary standards for nutrition and hydration, but does not include further details about the circumstances or the resident's condition.
A resident with moderate cognitive impairment and multiple diagnoses experienced significant unmonitored weight loss over several months. Facility staff failed to consistently document weights, perform reweighs, or notify the physician and dietitian as required. Dietary interventions were inconsistently applied, and staff interviews revealed a lack of awareness and follow-up regarding the resident's nutritional status.
A resident with dysphagia and a physician order for nectar thickened liquids was repeatedly served thin, regular consistency beverages at meals, contrary to the prescribed diet and speech therapy recommendations. Staff confirmed the error, and the resident was placed at risk for swallowing complications due to the facility's failure to follow the care plan.
A resident with significant weight loss and a physician's order for health shakes with meals did not receive the supplement with breakfast due to a failure to update the dietary slip and communicate the order to the kitchen. Staff and the resident confirmed the omission, and the dietician noted the supplement was only provided at lunch and dinner, not breakfast.
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