A resident with ESRD and dialysis had an ordered 1500 mL fluid restriction, but the restriction was not clearly broken down, documented, or monitored across nursing and dietary. The tray ticket did not show the restriction, no I&O sheet was available, CNA fluid documentation was inconsistent, and staff across departments gave conflicting accounts about whether the restriction was being tracked or counted, including the Nepro supplement and other fluids given with meals and meds.
Failure to Verify Significant Weight Loss: A resident at risk for malnutrition with DM and dysphagia had a >5% weight loss in less than 30 days, but staff did not timely reweigh or document the change. The UM and DON said weights were supposed to be reviewed and rechecked promptly, yet the resident’s loss was missed until the surveyor raised it, and the resident was later found to have continued losing weight.
Failure to identify significant weight loss was cited for a resident with Alzheimer’s disease, leukemia, and dementia who was dependent on staff for all care. The resident lost 5.1% of body weight in one month, but the chart showed no nutritional interventions in place and no evidence that nursing, the RD, or the MD/NP were aware of the loss. Staff interviews confirmed that the weight was entered without comparing it to the prior weight, so the significant loss was missed.
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 address significant weight loss: A resident with stroke, DM, and kidney disease lost more than 5% of body weight in one month and continued to lose weight, but the record did not show timely nutritional interventions. The RD knew of the weight loss, noted the resident had a good appetite and food preferences affected intake, yet no supplement was started and the nutritional assessment was incomplete. The resident said a supplement had not been offered, and nursing staff were unaware of the significant weight loss.
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.
A resident with DM, CKD, GERD, vitamin deficiency, and vascular dementia experienced a significant weight loss that was not promptly identified because required weights were not obtained and reviewed. The resident's nutrition assessment was completed just before the loss was documented, no additional dietary assessment was done after the loss, and a requested reweight was not shown as completed in the record.
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