Failure to follow a resident’s fluid restriction and diet order. A resident with MI and CKD had orders for 1500 cc fluid restriction, NAS diet, Lasix for edema, and daily weights, but was observed consuming fluids beyond the ordered limit, the tray card listed beverages totaling 1800 cc per day, and staff did not consistently document fluid intake or daily weights. Staff interviews showed confusion about tracking fluids, and the care plan did not reflect the ordered fluid restriction and related monitoring.
Failure to monitor significant weight change: A resident with Alzheimer’s disease and severe cognitive impairment was on a modified diet and initially documented as stable, but monthly weights showed an 8.6-lb gain, no reweigh was done within 24 hours, and the RD was unaware of the change. The care plan was not updated after the significant weight increase, despite the facility’s weight procedure requiring reweighing for a 5-lb change.
A resident with post-stroke apraxia, dysarthria, and right-sided weakness was dependent on staff for food and fluids, but was found thirsty with dry lips, limited bedside water, and no reliable way to summon help. Staff stated he could not use the call light, the communication board was not in his room, and the EMR showed no consistent fluid intake documentation or monitoring. The resident indicated he had not been receiving showers and could not give himself drinks of water.
Failure to appropriately assess and timely address unintentional weight loss for a resident with vascular dementia, severe cognitive impairment, and muscle weakness. The resident’s weight steadily declined from 142 lbs to 124.4 lbs, and RD notes documented delayed recognition and intervention, including late documentation of weight loss and delayed changes to med pass 2.0 and weekly weights. The NHA, DON, and Regional RD confirmed the delay, and the DPOA stated he was not informed about the resident’s weight loss or the med pass 2.0 intervention.
The facility failed to consistently monitor hydration, meal intake, and weight trends for residents at risk for altered nutrition and hydration. One resident with dementia, diabetes, and stroke history had lab values consistent with dehydration and was repeatedly observed with fluids untouched and meals largely uneaten, while staff reported fluid intake was not tracked consistently. Another resident with dementia had a 16-day gap in FAR documentation and a significant weight loss without a reweight, and a third resident with Parkinson’s disease and dementia had incomplete ordered weight monitoring and reported needing more feeding setup assistance and adaptive utensils.
Staff failed to provide timely bedside water to multiple cognitively intact and cognitively impaired residents, some with significant comorbidities such as CVA, CHF, COPD, diabetes, and severe protein-calorie malnutrition. During a daytime survey window, several residents were observed without water at bedside; some reported not receiving fresh water since the prior night or since breakfast and described using alternative containers or having cups removed and not replaced. Assigned CNAs acknowledged that they had not yet passed water during their shifts, despite the DON’s expectation that fresh water be passed by mid-morning and before the end of the shift, and despite a facility policy requiring that each resident be provided bedside water.
Failure to Monitor and Assess Significant Weight Loss: Two residents had significant weight changes without adequate monitoring, assessment, or documented interventions. One resident on PEG tube feeding had severe weight loss with no progress note documentation and an incomplete nutrition assessment, while another resident with aphasia and dysphagia had severe weight gain followed by severe weight loss, missed weight documentation, and no RD or provider reassessment despite diet orders and meal supervision needs.
Two residents did not receive adequate and consistently monitored nutrition and hydration. One resident with severe cognitive impairment, multiple chronic conditions, and a respiratory infection had highly inconsistent and contradictory meal-intake documentation over several days, with missing meals, entries recorded before typical meal times, and no reliable record of whether three daily meals were provided, despite a care plan requiring staff to monitor and record intake. Another resident with DM and ESRD on hemodialysis left for early-morning dialysis without breakfast or a sack meal, sometimes did not receive an HS snack, and had dialysis communication forms repeatedly indicating no meal or snack sent, while care plans and task documentation lacked clear interventions or consistent records for HS snacks or pre-/post-dialysis nutrition.
A resident with quadriplegia and dependence for all ADLs was repeatedly documented as weighing about 149 lbs by Hoyer lift, despite appearing very thin on observation. A December weight of 121.6 lbs was crossed out by an LPN as incorrect, and subsequent entries again showed weights near 149 lbs. When surveyors observed staff reweigh the resident with a mechanical lift, the actual weight was 120 lbs, nearly 30 lbs less than the most recently charted value. The RD stated the weights had appeared stable and therefore had not raised concern, and the DON reported that CNAs obtained and entered weights but did not explain the discrepancy. No facility policy on weight management or obtaining accurate weights was provided when requested.
A resident with severe protein-calorie malnutrition, dysphagia, and significant weight loss had care plans ordering Mighty Shake and Magic Cup TID with meals, but the supplements were frequently missing from meal trays. A family member reported they were absent most of the time, staff observed meals without the ordered supplements, and the RD confirmed one supplement was missing even though the MAR-TAR documented it as given.
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