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.
Failure to timely address and communicate significant weight loss. A resident had repeated hospital transfers/readmissions and showed major weight loss on facility weights, including a 12.7% loss followed later by another 6.7% loss. The RD documented weight loss and added nutrition interventions, but there was no evidence the changes were reported to the family or attending MD. Interviews showed conflicting staff understanding of who was responsible for notifying family/providers, and the DON, ADON, and Regional DON validated the concern.
Facility staff failed to follow dietitian recommendations and physician follow-up for two residents with weight loss and malnutrition. For one resident with dementia, FTT, and mild protein-calorie malnutrition, staff did not obtain or file results of an ordered GI telehealth consult and missed one of the weekly weights ordered by the dietitian. For another resident with malnutrition, staff obtained only two of four recommended weekly weights, and the dietitian did not reassess the resident after the initial evaluation. These inactions resulted in incomplete monitoring and follow-up for residents identified as experiencing weight loss.
Failure to provide ordered double portions: An underweight resident with declining wt was supposed to receive a regular diet with double portions of entree and vegetables, but surveyors found the lunch tray missing the protein and the 2 chicken salad sandwiches listed on the meal ticket. The resident confirmed the sandwiches were not received, and the dietary mgr later confirmed the resident should have gotten them.
Failure to Timely Address Significant Weight Loss: The facility did not consistently respond to significant resident weight changes. Records showed one resident with major weight loss over several months, another with severe loss in 30 days, and a third with a 13% weight change in one month. The RD and DON confirmed that weight loss should trigger re-weighing, assessment, documentation, and provider notification, but the survey found delayed assessments, missing documentation, and no evidence that the provider was timely notified for the affected residents.
Failure to provide ordered 1:1 meal assistance and required fluids: A resident with dysphagia and a physician order for 1:1 assist with meals was observed eating without staff present, while the breakfast tray was missing thickened milk and orange juice listed on the meal ticket. The resident’s care plan included 1:1 meal assistance and monitoring for swallowing difficulty, and RN staff confirmed the resident was eating unassisted with liquids missing from the tray.
Failure to Timely Address Significant Weight Loss: Two residents had significant, documented weight loss that was not addressed in a timely manner. One resident had major weight loss after hospitalizations, with no documented assessment or intervention after the first loss and no prompt follow-up weight check after the second. Another resident had a 5.5% weight loss in one week, but the MD progress note did not address it and the dietitian note was delayed. The DON and dietitian validated the concerns.
A resident with dysphagia and an aspiration precaution order requiring upright positioning, oral care, small bites and sips, and 1:1 meal assistance was observed lying in bed and trying to eat without staff present. The resident was later seen again alone with a meal tray, and an LPN confirmed the resident was not receiving the ordered continuous feeding assistance; the DON stated that 1:1 feeding requires continuous staff presence.
Failure to monitor weights for residents at risk for malnutrition. Three residents with poor PO intake and documented malnutrition diagnoses did not have follow-up weights obtained after admission. One resident had moderate acute malnutrition with poor intake and family discussion about an appetite stimulant, another had severe chronic malnutrition and reported possible recent weight loss, and a third had severe acute malnutrition with a large discrepancy between hospital and facility weights. The CNM confirmed the missing weights and stated the residents should have been reweighed.
Unaddressed Significant Weight Gain: A resident with MDD, PVD, above-the-knee amputation, and dementia had repeated significant weight gain over several months. The RD documented triggers for weight gain, questioned scale discrepancy or fluid shifts, and noted mirtazapine as a possible appetite stimulant, but the record did not show that the ongoing weight gain was acknowledged in the care plan or that interventions were adjusted.
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