Failure to Implement and Monitor Ordered Fluid Restrictions
Summary
The facility failed to ensure staff followed ordered fluid restrictions for three residents with significant cardiac and renal conditions. One resident with pulmonary hypertension, bradycardia, and heart failure had an RD-ordered 1500 ml/day fluid restriction, with 840 ml to be provided by dietary and 660 ml by nursing. The MAR showed this resident received 1680 ml of fluid in a 24-hour period, exceeding the ordered restriction. The resident’s care plan was not updated to include the fluid restriction until several days later, and the CNA care plan did not include monitoring of the restriction as a task. During a lunch observation, the resident received no fluids, and the meal ticket did not contain any information about the fluid restriction. The CNA caring for the resident stated she did not know the resident was on a fluid restriction, and the DM confirmed there was no fluid restriction noted on the meal ticket, despite facility fluid restriction instructions specifying a set amount of fluid to be provided at lunch. A second resident with congestive heart disease, chronic kidney disease, and diabetes had a physician’s order for a renal diet and a 2000 ml/day fluid restriction, with 740 ml assigned to nursing and 1260 ml to dietary. There was no care plan addressing fluid restriction for this resident, and the CNA care plan did not include monitoring of the restriction. Meal tickets for breakfast, lunch, and supper contained no documentation of a fluid restriction. During observation, the resident had a full facility-provided water pitcher of approximately 960 ml on the overbed table and 480 ml of fluid on the meal tray. The resident reported that dietary and nursing did not follow the fluid restriction and routinely provided two to three cups of fluid at each meal and a full water pitcher daily. The DM verified there was no fluid restriction noted on the meal ticket, although the facility’s fluid restriction instruction sheet specified a lower fluid amount to be provided at lunch for this level of restriction. A third resident with end stage renal disease and dependence on dialysis had physician’s orders for a renal diet and a 1500 ml/day fluid restriction, with 840 ml assigned to nursing and 660 ml to dietary. There was no care plan for fluid restriction, and the CNA care plan did not include monitoring of the restriction. Meal tickets for all meals lacked any documentation of a fluid restriction. Dialysis records showed the resident was over dry weight with 1500 ml of fluid removed on one date and 3000 ml removed on another. During observation, the resident had a facility-provided water container of approximately 720 ml on the overbed table and 240 ml of fluid on the meal tray. The resident stated that dietary and nursing did not follow the fluid restriction and that CNAs filled a 20-ounce personal water cup one to two times per day, and also reported being verbally counseled by the dialysis nurse for being over dry weight due to excessive fluid intake. The UM and Administrator confirmed that residents on fluid restrictions should have water pitchers removed, and that fluid restrictions should be documented on CNA care plans and meal tickets and followed by both nursing and dietary, as required by the facility’s “Encouraging and Restricting Fluids” policy.
Penalty
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Two residents experienced deficiencies in hydration and nutritional monitoring when staff failed to ensure accurate tube-feeding flush orders, adequate hydration assessment, and consistent weight monitoring. One resident, fully dependent on enteral feeding, had a tube-feed order written with a free water flush only every 22 hours, received no weekly weights as requested by the RD, and later developed severe hypernatremia and dehydration requiring hospital transfer. Another morbidly obese resident with chronic respiratory failure and heart failure had large, unplanned weight gains over several months without regular weights, physician weight orders, or in-depth nutritional assessments, and the RD reused old weights and completed assessments without in-person evaluation, resulting in documentation that did not reflect the resident’s true nutritional status.
Two residents with severe cognitive impairment and documented abnormal weight loss experienced significant, ongoing weight decline while the facility failed to implement a comprehensive, resident-centered nutrition plan. For one resident with Alzheimer’s and prior hospital weight loss, an RD recommended supplements, but no specific supplement order was written, weights were not consistently updated in the EHR, meal intake percentages were frequently undocumented, and multiple MD/FNP visits did not address the continued weight loss. For another resident with protein-calorie malnutrition and multiple comorbidities, there was no initial comprehensive nutrition assessment, no care plan for weight loss, and no evidence that RD-recommended house shakes twice daily were implemented, despite marked weight drops. Facility staff inconsistently documented meal intake, used a non-standardized whey protein "house supplement" instead of the RD-recommended Ready Pass for most residents, and prepared this supplement without a set recipe, while the MD was unaware of its use.
A resident with severe cognitive impairment, a history of right femur fracture, anemia, and A-fib was care planned as at risk for dehydration and protein-calorie malnutrition, with interventions including regular weight monitoring and nutritional support. Initial weights and a nutrition assessment showed low oral intake and the need for supplements, but after hospitalization and readmission for surgical repair of a femur fracture, staff did not obtain a new admission weight as required by facility policy. Instead, NP progress notes repeatedly relied on an auto-populated weight from a prior month, and no current weight was documented until weeks later, when significant weight loss and temporal wasting were noted and the resident was identified as having ongoing poor intake and cachexia. A corporate RN confirmed that a readmission weight should have been obtained and was not, resulting in failure to adequately monitor the resident’s weight loss.
A resident with multiple comorbidities, dysphagia, and cognitive impairment was admitted and initially refused to be weighed, but staff made no further documented attempts to obtain weights despite an order for weekly weights and a facility policy requiring an admission weight and ongoing monitoring. Staff relied on a hospital weight while diet orders and texture modifications were made, and a dietitian note referenced the hospital weight and recommended a protein supplement for a sacral wound. When the resident was eventually weighed, the result showed an 11.8% loss from the hospital weight, yet no reweigh was completed within 24 hours and no dietitian evaluation of the significant loss was documented, contrary to the facility’s weight/reweigh policy.
The facility failed to consistently document meal intake for two residents who had significant weight loss or were at nutritional/dehydration risk, despite care plans and physician orders identifying the need for monitoring. One resident with dementia, diabetes, and a history of significant weight loss had only about one‑third of meals documented over a month, with many days lacking any recorded intake, even though she was ordered a regular diet and supplements and was identified as at risk for malnutrition. Another resident with ESRD, respiratory failure, CHF, and on dialysis had multiple missing meal percentage entries across two months, including entire days without any documented intake, despite being care planned for nutritional risk. Staff interviews confirmed that meal intakes were expected to be documented in the EMR and that trays for residents away at appointments should be saved and offered later, but the Administrator and DON acknowledged that required intake documentation was missing.
A dependent resident with severe cognitive impairment, multiple chronic conditions, and documented fluid needs of approximately 1500–1700 ml/day received significantly less fluid than required over multiple days, with recorded intakes ranging from 600 to 1100 cc/day. On the observed day, the resident was only given about 240 cc of fluid at breakfast and 240 cc at lunch, plus a small amount of water with medications, and was not offered additional fluids while seated in a lounge or after being returned to bed. CNAs and an LPN confirmed they did not provide beverages outside of meals, despite a care plan for dehydration risk and a facility hydration policy requiring sufficient fluids, fresh water availability, and fluids with medication passes.
Failure to Ensure Adequate Hydration and Nutritional Monitoring for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient fluid intake and adequate monitoring of nutritional status for two residents who were dependent on staff for nutrition and hydration management. One resident with respiratory failure, hypertension, and dysphagia was totally dependent on enteral tube feeding and had a care plan identifying risk for altered nutrition and hydration, with interventions including monitoring for dehydration and reviewing labs. A progress note documented that this resident was NPO with a feeding tube, had significant weight loss, and was on Isosource 1.5 at 70 mL with a 200 mL free water flush every four hours, but the order was changed to Isosource 1.5 at 70 mL with a 55 mL free water flush. The physician order was written as Isosource 1.5 at 70 mL/hr, off two hours for ADL care, with a free water flush of 55 mL every 22 hours, and this order carried an end date several months later. MAR/TAR review showed the tube feed and flush were administered as ordered, but the flush frequency remained every 22 hours. In the weeks and months that followed, there was no evidence of weekly weights as requested by the RD; only monthly weights were documented. The resident was cognitively intact and required some assistance with ADLs. On the day of the acute event, progress notes described the resident as lethargic, with a moist cough, fever, tachycardia, and dry mucous membranes, and staff documented a change in condition. Orders were obtained for labs, chest x-ray, oxygen as needed, Tylenol, antibiotics, Duoneb, close monitoring of vital signs, extra IV fluids including a bolus of normal saline followed by continuous infusion, and a one-time water bolus via the feeding tube. Critical lab results showed a sodium level of 173 mmol/L, elevated BUN, and reduced GFR, and the resident was transferred to the hospital. Hospital documentation identified hypernatremia from free water deficit and acute kidney injury from dehydration, with toxic metabolic encephalopathy significantly due to dehydration and hypernatremia. Interviews with the ADON, regional nurse, and RD revealed uncertainty about why the flush order was written every 22 hours, acknowledgment that the pump could not run feed and flush simultaneously, lack of documentation that staff were monitoring or inputting formulas correctly, and no clarification of flush orders despite risks of too little flushing and dehydration. The facility’s hydration and feeding tube policies, which required providing sufficient fluids and maintaining acceptable nutritional and hydration status, were not implemented. The second resident had chronic respiratory failure, ventilator dependence, heart failure, and morbid obesity, and required assistance with ADLs. The care plan identified high BMI and obesity with interventions including monitoring and reporting changes, assisting with ADLs, following physician orders, and monitoring weights. Nutrition and hydration assessments documented the resident at 399 pounds on a low concentrated sweets diet with regular texture and interventions of weight monitoring per physician orders, but a later assessment was identical to one completed approximately four months earlier and was not locked until months after its stated date. Weight summaries showed the resident weighed 381 pounds in July, 398.9 pounds in October, and 557.8 pounds in April, indicating a gain of 159 pounds over five months, yet the resident was not being weighed weekly, bi-weekly, or monthly, and there were no physician orders for weight monitoring. A nutrition review note cited significant weight change and new orders for daily weights for a week, but the medical record contained no documentation of physician notification, weight orders, consistent weight monitoring, or in-depth assessments related to the significant weight gain, and only two documented refusals of weights with no further attempts. Staff interviews confirmed that CNAs were responsible for weighing residents according to orders and that most residents were weighed monthly unless otherwise directed, but this resident was not on any list for daily, weekly, or monthly weights, and staff could not recall when she was last weighed. An LPN described the resident as morbidly obese and at nutritional risk due to size, eating habits, diagnoses, and skin issues, and stated the RD followed her to maintain baseline health, yet verified there were no weight orders. The RD reported that the resident had significant weight gain, was on fluid restrictions for presumed water retention, and that she only received updates during Friday risk meetings. The RD acknowledged awareness of over 100 pounds of weight gain, confirmed there were no orders for daily, weekly, or monthly weights and no ongoing documented refusals, and admitted that a January assessment reused a previous weight because no new weight was available. The RD further stated she had not assessed the resident in person and completed documentation using prior assessments and other record information, acknowledging that the medical record did not accurately reflect the resident’s current nutritional health status. The facility’s failure to monitor and document weights, obtain and follow weight orders, and perform accurate, timely nutritional assessments contributed to inadequate monitoring and implementation of interventions to maintain proper nutritional health for this resident.
Failure to Assess, Monitor, and Implement Nutritional Interventions for Residents With Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to provide a comprehensive, resident-centered plan of care to prevent, timely identify, and treat weight loss, as well as failures in obtaining, documenting, and monitoring weights, documenting meal intake, and providing and preparing nutritional supplements as ordered. For one resident with Alzheimer’s disease, generalized anxiety, and abnormal weight loss, the RD/Administrator recommended adding four ounces of a nutritional supplement between or with meals, but no specific supplement type was documented and no corresponding physician order was entered. Despite documented abnormal weight loss prior to admission and subsequent significant weight loss after admission, multiple progress notes by the FNP and the Medical Director did not address the ongoing weight loss beyond general statements to monitor weight and intake. The resident’s weight declined from 156.8 lbs. prior to admission to 132 lbs. in February and then to 125.5 lbs. in April, yet there were no physician orders for supplements as recommended by the RD, and the resident’s meal ticket did not include any nutritional supplements. The same resident’s care plan, revised later for a nutritional problem related to weight loss prior to admission, contained general interventions such as encouraging compliance with diet and medications, monitoring weights as necessary, and providing supplements when awake or when intake was less than 75 percent. However, there was no evidence that specific supplement orders were written or implemented, and the MDS assessment did not reflect the resident’s weight loss. Meal intake documentation for this resident was incomplete and inconsistent, with multiple dates where no meal percentages were recorded and unclear documentation regarding whether supplements were received or accepted. Observation during a lunch meal showed the resident receiving a sandwich and grapes in the lobby, with no supplement observed. The RD acknowledged that staff were not consistently completing meal intake documentation, and the Medical Director stated he was unaware of the severe weight loss because current weights were not updated in the electronic record, making it appear that the weight had stabilized. For another resident with multiple diagnoses including moderate protein-calorie malnutrition, osteoporosis, diabetes, delusional disorder, and a history of falls and fractures, the facility also failed to adequately assess and address nutritional needs and weight loss. This resident experienced significant weight loss from 109 lbs. on admission to 103.5 lbs. within about two weeks, and then to 102.5 lbs., with the RD documenting that the resident was underweight for age and had a 5.9 percent weight loss in 30 days. The RD recommended adding house shakes twice daily for additional calories and protein and reported that the resident was added to the supplement list, but there was no evidence in the medical record that these recommendations were implemented. The resident’s weight later dropped to 89.5 lbs., a 12.68 percent loss in five days, without documentation of a reweigh to verify accuracy. There was no initial comprehensive nutritional assessment from the first admission to determine nutritional needs, and no care plan addressing the resident’s nutritional status or weight loss. Interviews revealed that the house supplement was made from a whey protein powder blend with creatine and amino acids, prepared without a standardized recipe, and that most residents received this house supplement rather than the Ready Pass supplement the RD had recommended for residents needing nutritional support. The Medical Director was not aware the whey protein powder was being used.
Failure to Obtain Readmission Weight and Monitor Nutritional Status
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document required weights to monitor for weight loss in a resident identified as being at risk for dehydration and protein-calorie malnutrition. The resident was admitted with diagnoses including a right femur fracture, acute posthemorrhagic anemia, and atrial fibrillation, and was assessed as severely cognitively impaired with documented issues of coughing and choking during meals and holding food in the mouth. The care plan, initiated shortly after admission, identified risk for dehydration and malnutrition and included interventions such as obtaining weights and nutritional consults. Early weights were documented in late January and February, showing a weight around 100 lbs, and the admission nutrition assessment noted an average intake of 50%, likely inadequate to meet energy needs, with fortified pudding and supplements added. Following a fall and surgical repair of a right femur fracture, the resident was readmitted to the facility, but no admission weight was documented at readmission, contrary to facility policy requiring a weight within 24 hours of admission. Subsequent NP post-hospital visit notes on multiple dates used an auto-populated weight from mid-February (99.8 lbs) rather than a current measured weight, and there was no new documented weight until early April, when the resident’s weight was recorded at approximately 93 lbs. Later NP and dietary notes described ongoing poor oral intake, temporal wasting, and weight loss, and a nutrition-at-risk note confirmed weight loss since late January due to low oral intake. A corporate RN confirmed that a weight should have been obtained upon readmission and verified that this was not done, resulting in inadequate monitoring for weight loss as required by the resident’s care plan and facility policy.
Failure to Monitor and Reweigh Resident After Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to accurately and timely monitor a resident’s weight, resulting in an undetected and unevaluated significant weight loss. The resident was admitted with multiple diagnoses including cerebral infarction, dysphagia, diabetes, morbid obesity, sepsis, bipolar disorder, anxiety disorder, hypertension, osteoarthritis, and peripheral vascular disease. On admission, the resident refused to be weighed, and the admission assessment documented this refusal. A physician’s order was in place for weekly weights for four weeks, but there was no evidence of further attempts to obtain weights between admission and a later date, and no additional refusals were documented. The facility’s policy required a weight within 24 hours of admission and prohibited use of hospital weights in lieu of actually weighing the resident. Subsequent orders changed the resident’s diet texture and thickened liquid consistency, and the MDS assessment showed the resident had short- and long-term memory problems and required substantial/maximal assistance with eating. A dietary note documented a hospital weight of 220 lbs, variable intake, and a sacral wound, and recommended a protein supplement for wound healing, which was ordered by the physician. When the resident was finally weighed, the weight was 194 lbs, reflecting a 26-lb (11.8%) decrease from the hospital weight. There was no evidence that this significant loss triggered a reweigh within 24 hours as required by policy, and no dietitian evaluation of the significant weight loss was documented. A nurse practitioner later documented that the resident was minimally responsive with additional neurologic signs and the resident was sent to the hospital and did not return. The regional nurse consultant confirmed the lack of interim weight attempts, lack of reweigh after the significant loss, and lack of evaluation of that loss.
Failure to Consistently Document Meal Intake for Residents at Nutritional Risk
Penalty
Summary
The deficiency involves the facility’s failure to consistently document meal consumption for residents with significant weight loss or identified nutritional risk, preventing adequate monitoring of their nutritional status. One resident with dementia, diabetes, depression, anxiety, and vitamin deficiencies was admitted at 154.4 pounds and had a documented downward weight trend to 140 pounds after three months and then to 130 pounds. Her care plan identified her as at risk for nutrition with a history of significant weight loss at one, three, and six months, with goals to avoid unplanned significant weight changes and interventions including a regular diet, offering substitutes, providing ordered supplements, and documenting consumption. Physician orders noted she was at risk for malnutrition and prescribed a regular diet and house supplements twice daily. However, review of her meal intake records over a 30‑day period showed that only 29 of 90 meals had documented intake, with no documentation at all for any of the three meals on 16 separate days and incomplete documentation on several other days. Staff interviews further confirmed the lack of consistent documentation for this resident. A CNA reported that the resident ate breakfast in the dining room and usually had lunch and supper with family in her room or while out on drives, and that her appetite varied by day. The CNA stated that if the resident ate less than 50% of a meal, staff would offer alternatives, but she was not aware of the resident receiving supplements or having weight loss, and there were no supplements available for the resident in the container at the nurses’ station that day. An LPN verified that the resident’s meal percentages were not being consistently recorded in the EMR, acknowledging that only about one‑third of the resident’s meals were documented and that this information was important for the dietitian when determining nutritional interventions related to weight loss. A second resident, admitted with end stage renal disease, respiratory failure, hyperlipidemia, and congestive heart failure, had impaired cognition and required set‑up/clean‑up assistance with meals and was care planned as being at nutritional and/or dehydration risk due to recent surgery, CHF, dialysis, increased needs, and skin alteration. Interventions included assisting with meals and providing the ordered diet. This resident had multiple missing meal intake entries over March and April, including entire days with no documented breakfast, lunch, or dinner, and numerous individual meals without recorded percentages. Interviews with dietary and CNA staff indicated that trays for residents away at dialysis should be returned to the kitchen, stored in the fridge, or placed in the server room until the resident returned, and that meal intakes should be documented in the computer. The Administrator and DON confirmed the missing meal percentage documentation, and facility policy required accurate records of residents’ food intake to be completed by assigned personnel.
Plan Of Correction
1. On 5/6/26 the Director of Nursing reviewed Resident # 5 and determined there was no ill effect related to the missing meal documentation and the resident's weight remains stable. On 5/6/26 the Director of Nursing reviewed Resident # 12 and determined there was no ill effect related to the missing meal documentation and the resident's weight remains stable. 2. Like Residents are identified as residents who receive meals from the facility. Utilizing the Meal Intake Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, an audit of identified residents will be completed by the Director of Nursing or designee to ensure they have diet orders in PCC and meal intake is being documented in PCC. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing designee will re-educate licensed nurses and STNA's on the Food Acceptance Policy to include documenting meal intake in POC. This education will be completed on or before 5/13/26. 4. Utilizing the Meal Intake Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit 4-6 residents weekly for four weeks, beginning 5/14/26 to ensure they have diet orders in PCC and meal intake is being documented in PCC. Noncompliance noted during audits will be corrected to ensure diet orders are in PCC and meal intake is being documented in PCC. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Failure to Provide Adequate Hydration to Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate fluids to maintain the health of a dependent resident who was at risk for dehydration. The resident had multiple diagnoses including congestive heart failure, COPD, type 2 diabetes, morbid obesity, chronic respiratory failure, anxiety disorder, hypertension, dementia, chronic peripheral venous insufficiency, osteoarthritis, transient ischemic attack, and dependence on supplemental oxygen. The most recent MDS documented severe cognitive impairment, dependence on staff for all ADLs including transfers and repositioning, incontinence of bowel and bladder, risk for pressure ulcer development, and admission with a stage 2 pressure ulcer. A dietary assessment identified estimated fluid needs of 1496–1700 ml/day and risk for malnutrition, with average meal intake between 26–100%. A nursing care plan was initiated to address risk for dehydration related to diuretic use, with interventions including providing diet as ordered and administering medications per orders. However, documented daily fluid intake from 04/01/26 to 04/07/26 ranged only from 600 to 1100 cc per day, below the resident’s estimated fluid needs. On the observed day, the resident was seated in a wheelchair in the lounge from early morning until mealtimes and was only observed to receive fluids during breakfast and lunch. At breakfast, the resident was provided 240 cc of fluid, and at lunch another 240 cc of fluid, with no additional fluids observed being offered between or outside of these meals while the resident remained in the lounge and then was later taken to bed. CNA staff interviewed confirmed they had not provided any beverages to the resident other than during breakfast and lunch, and each was unaware if the other had offered additional fluids. The LPN reported giving only a small amount of water with morning medications and no further fluids aside from those at meals. This pattern of limited fluid provision conflicted with the facility’s General Hydration Services policy, which states that residents are to be offered sufficient fluids consistent with their needs and preferences, including drinks at meals, fresh water at bedside when appropriate, and fluids with medication passes.
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