A resident admitted with muscle wasting and atrophy had documented weight changes from 164 lbs to 178.6 lbs, then dropped to 156.6 lbs, triggering a Dietitian note for significant weight loss and a reweight request. The reweight was delayed, the resident was later documented at 153 lbs, and no further Dietitian follow-up or additional nutritional interventions were put in place after the weight loss was identified; staff also did not follow the facility’s weekly weight monitoring schedule for newly admitted residents.
Missed Ordered Weights and Incorrect BMI Documentation: Two residents had weight monitoring ordered by the RD, but the chart lacked documentation that weights were obtained on multiple required dates. One resident’s height was initially recorded as 51 inches, which produced an inaccurate BMI, and was later clarified to be 65 inches. Staff interviews and record review showed gaps in weight documentation, including missed weekly and monthly weights and no clear documentation of refusals for most missed entries.
Failure to timely assess and monitor residents’ nutrition needs. A resident with dysphagia and weight loss did not receive a timely RD assessment or documented nutrition follow-up after an NP ordered a consult, and later continued to lose weight before being seen again. Another resident admitted with dysphagia had a delayed admission nutrition assessment and missed weight monitoring. A third resident with brittle DM, variable BGs, and DKA had no recent comprehensive nutrition assessment or dietary notes for months, despite the MD stating close follow-up was expected.
Failure to Report Significant Weight Loss: A resident had a documented 5.7% weight loss over 1 month, but nursing staff did not notify the RD or provider and instead waited for a reweight due to concern about scale accuracy. The resident’s care plan required reporting significant weight loss, yet the chart contained no RD or physician notes addressing the change, even after the resident was reweighed and the DON acknowledged the weight alert process.
Failure to Monitor Weight Loss and Nutritional Status: A resident with multiple hospital transfers and readmissions had inconsistent weight monitoring, including a delayed post-readmission weight record and a documented 8.6-lb loss in 10 days. The Dietitian confirmed the lack of required weight documentation after the most recent readmission and that no interventions or follow-up care were provided for the significant weight loss; the DON validated the findings.
A resident identified as malnourished on admission was ordered to have weekly weights, but only three weights were obtained after admission and the resident was not weighed as ordered during the first 4 weeks. The RD documented a nutrition problem and said she monitored weights in PCC, but later acknowledged she could not say she specifically looked at this resident’s weights. The DON stated new admissions should be weighed within 24 hours and then weekly if stable, but the ordered monitoring was not carried out.
Failure to provide ordered nutritional supplements: A resident with a physician order for Magic Cup and Health shakes TID for risk of malnutrition reported not receiving them as expected. Survey observations found the supplements missing from breakfast and lunch trays and meal tickets, while the MAR documented them as administered. An LPN stated the items were obtained from the kitchen at breakfast and acknowledged they were documented as given before the resident actually received them.
Failure to provide a replacement meal after breakfast was not consumed. A resident with cognitive impairment and recent weight loss was observed away from the room while the breakfast tray remained untouched and the plate was found on the floor with oatmeal and eggs spilled. The DON was notified and housekeeping cleaned the spill, but there was no evidence the resident was assessed for intake or offered a replacement tray, substitute meal, or nutritional supplement. The CDM said no extra breakfast tray was requested, and an RN stated she was unaware the resident needed a replacement meal.
A resident with Parkinson’s disease and tremors was observed having difficulty feeding him/herself at breakfast, with food placement problems due to hand tremors and lethargy noted during the observation. The resident had been assessed as malnourished and was receiving nutritional supplements, but intake was partial or refused, and the care plan lacked interventions for reduced intake. The GNA believed the resident could feed independently, while the MD, dietitian, and DON were unaware of the feeding difficulty.
Failure to address and communicate significant weight changes for two residents. One resident had large, fluctuating weight changes with no documentation that the early drops and gains were investigated, re-weighed for accuracy, or addressed with interventions. Another resident had a 14.6 lb weight loss after hospitalization, but there was no evidence the provider was notified. The DON validated the lack of documented communication, and the Dietitian stated significant weight changes should be addressed and that nursing is responsible for reporting them.
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