A resident with esophageal obstruction, gastritis, malnutrition, and a history of a removed G-tube experienced a 20.52% weight loss in three months while remaining on a regular diet with Boost TID. Staff observed the resident appearing gaunt, struggling to swallow, gagging on saliva, and spitting chewed food into a bottle, yet nursing notes did not document intake or swallowing issues and the physician, RD, and ST were not notified of the significant weight loss as expected. The resident was not placed on weekly weights, the care plan was not updated to reflect the diet order, and the RD made no new recommendations at the earlier weight-loss review.
A resident who required extensive assistance with drinking did not have a care plan addressing fluid assistance, and staff repeatedly failed to offer fluids despite the resident’s dry lips, dry mouth, and frequent requests for water. Observations showed the water pitcher was often out of reach, and staff, including an NA and CNA, did not offer fluids when entering the room or providing care to the roommate. Interviews confirmed the resident could not use the call light and needed staff to anticipate and frequently offer fluids.
Surveyors found that the facility failed to implement RD recommendations and physician orders for fortified diets, finger foods, and nutritional shakes, and failed to provide needed meal set-up and encouragement for two residents with severe cognitive impairment and documented significant weight loss. One resident, ordered a fortified diet and later finger foods due to roaming during meals, continued to receive standard plated meals without finger foods, had no care-plan updates, and was observed having trays placed without set-up assistance and removed uneaten without encouragement or alternative offerings. Another resident with dysphagia and a fortified mechanical soft diet, ordered high-calorie nutritional shakes twice daily after further weight loss, did not receive the shakes at breakfast or lunch, and staff removed largely uneaten trays without supervision, encouragement, or substitutions, while the DM and dietary staff acknowledged that RD recommendations and diet orders were not correctly reflected on meal cards or implemented.
Failure to Track and Communicate Significant Weight Loss: A resident with cognitive impairment had a steady decline in wt, decreased appetite, and decreased energy, with losses progressing from stable weights to a 10-lb loss in one month and further decline over the next several weeks. Staff documented the wt loss at meetings but did not document MD or RD notification, and the care plan was not updated to reflect the ongoing unplanned wt loss or the interventions in place. The RD initially assessed the resident as stable and later noted significant negative wt change and decreased oral intake.
Failure to assist residents with meals and monitor intake. Two residents with dementia and other significant diagnoses were observed sitting in the dining room with untouched or poorly accessed meals while staff did not provide the ordered meal assistance, encouragement, or supervision. One resident was taken back to the room without being offered help, and the other was seen eating pureed food with a fork or butter knife despite an order for staff to offer assist with meals and a care plan calling for meal support.
Staff failed to administer and/or document physician-ordered nutritional supplement shakes for a cognitively intact resident on multiple days, with the MAR lacking entries for administration or refusal of the supplements. Leadership, including the administrator, DON, and ADON, stated that staff are required to document all administered or refused supplements and that monthly MAR/TAR reviews are expected, but the ADON reported that the February review was not completed due to covering additional MDS duties.
Failure to maintain hydration needs for a resident with paranoid schizophrenia, anxiety disorder, and BPH. The resident had a fluid restriction order that was later discontinued, but observations showed water placed out of reach while the resident remained in bed, called out for water, and stated being thirsty. Staff interviews confirmed the resident depended on staff for ADLs and often requested drinks, while the DON said staff were expected to offer fluids during care or when entering the room.
A resident with multiple chronic conditions and a mechanically altered diet experienced significant unplanned weight loss while also developing a pressure ulcer. Staff did not re-evaluate the care plan, notify the MD, RD, consultant pharmacist, or representative, or document intake monitoring for ordered Ensure supplements. During observation, the resident ate very little, had dry lips and a sunken appearance, and received no cueing or assistance during the meal.
A resident with multiple comorbidities, severe cognitive impairment, dependence for ADLs, and an unstageable pressure ulcer experienced a significant weight loss of nearly 14% over two months. Facility policy required investigation and intervention for significant weight changes, but weights were not consistently documented, and no specific weight-loss interventions were added to the care plan. The RD identified increased nutrient needs, recommended supplements (Pro Heal, Juven) and later recommended adding Magic Cup BID, but this recommendation was not communicated to the physician, not entered as a diet order, and not provided with meals, as confirmed by observations and interviews with the resident, family, LPN, RD, and Dietary Manager. Leadership staff stated they expected RD recommendations to be reviewed and communicated, but this did not occur, resulting in failure to implement and evaluate appropriate nutritional interventions for the resident’s weight loss.
A resident with DM2, anemia, and a below-knee amputation had gradual weight loss while on a regular diet with Magic Cup supplements. Meal observations showed the resident ate some foods but inconsistently consumed the supplement, including one meal where staff did not remove the lid. Staff interviews showed CNAs and a CMT were unaware of weight-loss monitoring, the DON said there was no current meal intake process, and the resident's intake was not being consistently documented.
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