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.
A resident with dysphagia experienced significant unplanned weight loss over several months due to staff failing to promptly follow the dietitian's recommendations for nutritional supplements and appetite stimulants, and not notifying the provider of continued weight loss. Despite monthly assessments, no further interventions were implemented, and the provider remained unaware of the ongoing decline.
A resident who was dependent on staff for feeding experienced a significant decrease in oral intake over several days, with missed meals and no updated nutritional assessment. Facility staff did not alert the dietitian or reassess the resident despite documented reduced intake. The resident's condition worsened, leading to hospitalization for dehydration after staff were unable to establish IV access and reported decreased intake to the hospital.
A deficiency was cited when a resident did not receive sufficient food and fluids to maintain their health, as required. The report indicates that the facility did not meet the necessary standards for nutrition and hydration, but does not provide further details about the circumstances or the resident's condition.
Two residents experienced deficiencies in nutritional care: one had significant unaddressed weight loss without follow-up or documentation, and another did not receive recommended dietary supplements for malnutrition and dysphagia, as staff failed to implement the dietitian's interventions. The DON confirmed these lapses.
A resident with malnutrition and a gastrostomy was not assessed by the dietitian in a timely manner after admission and multiple hospital transfers. The DON confirmed that the assessment did not occur within the expected timeframe, as required by facility policy.
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