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.
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.
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 Alzheimer's disease experienced significant, unaddressed weight loss after a CNA repeatedly falsified weight documentation over several weeks. Despite concerns raised by the resident's power of attorney about the resident's declining condition, facility staff assured them there was no weight loss, relying on inaccurate records. The deficiency was confirmed through interviews, record review, and video evidence, revealing that weights were not properly obtained or documented, resulting in neglect.
Two residents experienced significant weight loss after not consistently receiving prescribed nutrition, either through tube feeding or oral intake. One resident with complex medical needs did not receive the full volume of tube feeding on multiple occasions, while another had multiple undocumented or unverified meals. The registered dietician and DON confirmed gaps in both nutrition delivery and documentation, leading to unaddressed weight loss.
A resident with dementia who required full staff assistance experienced a significant weight loss over a short period, but staff failed to confirm the loss, notify the DON, or update the nutrition care plan as required by facility policy. The DON was not informed of the weight change, and no follow-up actions were documented.
A deficiency was cited when a resident was not provided with sufficient food and fluids to maintain their health, as required. The report does not include further details about the circumstances or the resident's condition.
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