CMS SOM App. PP, Tag F692

(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic

gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based

on a resident's comprehensive assessment, the facility must ensure that a resident—

§483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual

body weight or desirable body weight range and electrolyte balance, unless the

resident’s clinical condition demonstrates that this is not possible or resident

preferences indicate otherwise;

§483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and

health;

§483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and

the health care provider orders a therapeutic diet.

INTENT §483.25(g)

The intent of this requirement is that the resident maintains, to the extent possible,

acceptable parameters of nutritional and hydration status and that the facility:

• Provides nutritional and hydration care and services to each resident, consistent

with the resident’s comprehensive assessment;

• Recognizes, evaluates, and addresses the needs of every resident, including but

not limited to, the resident at risk or already experiencing impaired nutrition and

hydration; and

• Provides a therapeutic diet that takes into account the resident’s clinical condition,

and preferences, when there is a nutritional indication.

DEFINITIONS §483.25(g)

Definitions are provided to clarify clinical terms related to nutritional status.

“Acceptable parameters of nutritional status” refers to factors that reflect that an

individual’s nutritional status is adequate, relative to his/her overall condition and

prognosis, such as weight, food/fluid intake, and pertinent laboratory values.

“Artificial nutrition and hydration” are medical treatments and refer to nutrition that is

provided through routes other than the usual oral route, typically by placing a tube

directly into the stomach, the intestine or a vein.

“Clinically significant” refers to effects, results, or consequences that materially affect

or are likely to affect an individual’s physical, mental, or psychosocial well-being either

positively by preventing, stabilizing, or improving a condition or reducing a risk, or

negatively by exacerbating, causing, or contributing to a symptom, illness, or decline in

status.

“Dietary supplements” refers to herbal and alternative products that are not regulated by

the Food and Drug Administration and their composition is not standardized. Dietary

supplements must be labeled as such and must not be represented for use as a

conventional food or as the sole item of a meal or the diet.

“Health Care Provider” includes a physician, physician assistant, nurse practitioner, or

clinical nurse specialist, or a qualified dietitian or other qualified nutrition professional

acting within their state scope of practice and to whom the attending physician has

delegated the task. For issues related to delegation to dietitians, refer to §483.60(e)(2),

F808.

“Nutritional status” includes both nutrition and hydration status.

“Nutritional Supplements” refers to products that are used to complement a resident’s

dietary needs (e.g., calorie or nutrient dense drinks, total parenteral products, enteral

products, and meal replacement products).

“Therapeutic diet” refers to a diet ordered by a physician or other delegated provider

that is part of the treatment for a disease or clinical condition, to eliminate, decrease, or

increase certain substances in the diet (e.g., sodium or potassium), or to provide

mechanically altered food when indicated.

“Tube feeding” refers to the delivery of nutrients through a feeding tube directly into the

stomach, duodenum, or jejunum. It is also referred to as an enteral feeding.

GUIDANCE §483.25(g)

It is important to maintain adequate nutritional status, to the extent possible, to ensure

each resident is able to maintain the highest practicable level of well-being. The early

identification of residents with, or at risk for, impaired nutrition or hydration status may

allow the interdisciplinary team to develop and implement interventions to stabilize or

improve nutritional status before complications arise. Body weight and laboratory results

can often be stabilized or improved with time, but may not be correctable in some

individuals. Intake alone is not the only factor that can affect nutritional status. Resident

conditions and co-morbidities may prevent improved nutritional or hydration status,

despite improved intake.

Many factors can influence weight and nutritional status as one ages. The body may not

absorb or use nutrients as effectively, there may be changes in the ability to taste food, or

there may be a decreased sensation for thirst or hunger. The resident’s medical condition

can also affect how well they maintain weight, such as changes in muscle mass, cognitive

status, nearing end of life, or a disease process, such as kidney disease or congestive heart

failure, which may cause the resident to retain fluids in the body. While impaired

nutritional status is not necessarily expected as one ages, there could be times where

efforts to maintain good nutrition may pose extra challenges.

Failure to identify residents at risk for compromised nutrition and hydration may be

associated with an increased risk of mortality and other negative outcomes, such as

impairment of anticipated wound healing, decline in function, fluid and electrolyte

imbalance/dehydration, and unplanned weight change.. While food intake may be

considered, ensuring a resident receives the fluids they require can more easily be

overlooked. Individuals who do not receive adequate fluids are more susceptible to

urinary tract infections, pneumonia, pressure injuries, skin infections, confusion, and

disorientation.

A systematic approach can help staff’s efforts to optimize a resident’s nutritional status.

This process includes identifying and assessing each resident’s nutritional status and risk

factors, evaluating/analyzing the assessment information, developing and consistently

implementing pertinent approaches, and monitoring the effectiveness of interventions and

revising them as necessary. Weight loss, poor nutritional status, or dehydration should be

considered avoidable unless the facility can prove it has assessed/reassessed the

resident’s needs, consistently implemented related care planned interventions, monitored

for effectiveness, and ensured coordination of care among the interdisciplinary team.

ASSESSMENT

A comprehensive nutritional assessment should be completed on any resident identified

as being at risk for unplanned weight loss/gain and/or compromised nutritional status.

Through a comprehensive nutritional assessment, the interdisciplinary team clarifies

nutritional issues, needs, and goals in the context of the resident’s overall condition.

Completion of the RAI does not remove the facility’s responsibility to document a more

detailed resident assessment, when indicated, to identify possible effective interventions.

The nutritional assessment may utilize existing information from sources, such as the

RAI, assessments from other disciplines, the existing medical record, observation, direct

care staff interviews, and resident and family interviews. The assessment should identify

those factors that place the resident at risk for inadequate nutrition/hydration. The

nutritional assessment may include the following information:

General Appearance: General appearance includes a description of the resident’s

overall appearance (e.g., robust, thin, obese, or cachectic). Other findings that may affect

or reflect a resident’s nutritional status may be included, such as the resident’s cognitive

status, affect, oral health and dentition, ability to use the hands and arms, and the

condition of hair, nails, and skin.

Height: Measuring a resident’s height provides information that is relevant (in

conjunction with his or her weight) to his/her nutritional status. There are various ways

to estimate height if standing height cannot be readily measured.

1 A protocol for

determining height helps to ensure that it will be measured as consistently as possible.

Weight: Weight can be a useful indicator of nutritional status, when evaluated within the

context of the individual’s personal history and overall condition. Weight goals should be

based on a resident’s usual body weight or desired body weight. The facility should have

a procedure in place that includes, but is not limited to, establishing a consistent method

of weighing a resident (e.g. using the same scale, wearing the same clothes, weighing at

the same time of day, adjusting for use of a prosthetic, etc.), verifying the resident’s

weight upon admission, monitoring a resident’s weight over time to identify weight

loss/gain, verifying weight measurements when changes in weight occur, and reassessing

interventions when appropriate.

Current professional standards of practice recommend weighing the resident on

admission or readmission (to establish a baseline weight), weekly for the first 4 weeks

after admission and at least monthly thereafter to help identify and document trends such

as slow and progressive weight loss. Weighing may also be pertinent if there is a

significant change in condition, food intake has declined and persisted (e.g., for more

than a week), or there is other evidence of altered nutritional status or fluid and

electrolyte imbalance. In some cases, weight monitoring is not indicated (e.g., the

individual is terminally ill and requests only comfort care).

Examples of other factors that may impact weight and the significance of apparent weight

changes include the resident’s usual weight through adult life, current medical conditions,

diet and supplement orders, recent changes in dietary intake, and edema.

Suggested parameters for evaluating significance of unplanned and undesired weight loss

are:

Interval Significant Loss Severe Loss

1 month 5% Greater than 5%

3 months 7.5% Greater than 7.5%

6 months 10% Greater than 10%

The following formula determines percentage of weight loss:

% of body weight loss = (usual weight - actual weight) / (usual weight) x 100

Interviews with key staff members: The facility may identify key individuals who

should participate in the assessment of nutritional status and related causes and

consequences. For example, nursing staff provide details about the resident’s nutritional

intake. Physicians and non-physician practitioners help identify relevant diagnoses,

identify causes of weight changes, tailor interventions to the resident’s specific causes

and situation, and monitor the continued relevance of those interventions. Qualified

dietitians help identify nutritional risk factors and recommend nutritional interventions,

based on each resident’s medical condition, needs, preferences, and goals. Consultant

pharmacists can help the staff and practitioners identify medications and medication

interactions that may affect nutrition.

Food and fluid intake: The nutritional assessment includes an estimate of calorie,

nutrient and fluid needs, and whether intake is adequate to meet those needs. It also

includes information such as the route (oral, enteral or parenteral) of intake, any special

food formulation, meal and snack patterns (including the time of supplement or

medication consumption in relation to the meals), dislikes, and preferences (including

ethnic foods and form of foods such as finger foods); meal/snack patterns, and preferred

portion sizes. While there is no reliable calculation to determine an individual’s fluid

needs, an assessment should take into account those characteristics pertinent to the

resident, such as age, medical diagnoses, activity level, etc.

Fluid loss or retention: Fluid loss or retention can cause short term weight change.

Much of a resident’s daily fluid intake comes from meals; therefore, when a resident has

decreased appetite, it can result in fluid/electrolyte imbalance. Abrupt weight changes,

change in food intake, or altered level of consciousness are some of the clinical

manifestations of fluid and electrolyte imbalance. Laboratory tests (e.g., electrolytes,

BUN, creatinine and serum osmolality) can help greatly to identify, manage, and monitor

fluid and electrolyte status.

2

Altered Nutrient intake, absorption, and utilization: Poor intake, continuing or

unabated hunger, or a change in the resident’s usual intake that persists for multiple

meals, may indicate an underlying condition or illness. Examples of causes include, but

are not limited to:

• The inability to consume meals provided as a result of cognitive or functional

decline;

• Difficulty with chewing or swallowing food;

• An inadequate amount of food or fluid, including insufficient tube feedings;

• An uncomfortable or disruptive dining environment;

• The lack of adequate assistance or supervision;

• Adverse consequences related to medications; and

• Diseases and conditions such as cancer, diabetes mellitus, advanced or

uncontrolled heart or lung disease, infection and fever, liver disease, kidney

disease, hyperthyroidism, mood disorders, gastrointestinal disorders, pressure

injuries or other wounds, and repetitive movement disorders (e.g., wandering,

pacing, or rocking).

The use of diuretics and other medications may cause weight loss that is not associated

with nutritional issues. This may result in a planned weight loss (e.g. the reduction of

edema), but can also cause fluid and electrolyte imbalance/dehydration that causes a loss

of appetite and weight if unmonitored.

Early identification of these factors, regardless of the presence of any associated weight

changes, can help the facility choose appropriate interventions to minimize any

subsequent complications. Often, several of these factors affecting nutrition coexist.

Laboratory/Diagnostic Evaluation: Laboratory tests are sometimes useful to help

identify underlying causes of impaired nutrition or when the clinical assessment alone is

not enough to define someone’s nutritional status. An additional assessment of other

resident risk factors is often needed to confirm if a treatable clinical problem exists. For

example, low serum albumin levels may indicate malnutrition, but may also be the result

of an acute illness for reasons unrelated to nutrition. Therefore, albumin levels may not

improve, despite consumption of adequate amounts of calories and protein.

The decision to order laboratory tests by the health care provider and the interpretation of

subsequent results, is best done in light of a resident’s overall condition and prognosis.

Although laboratory tests such as albumin and pre-albumin may help in some cases in

deciding to initiate nutritional interventions, there is no evidence that they are useful for

the serial follow-up of undernourished individuals.

3

NOTE: If laboratory tests were done prior to or after admission to the facility and the test

results are abnormal, the physician or other licensed health care practitioner, in

collaboration with the interdisciplinary team, reviews the information and determines

whether to intervene or order additional diagnostic testing.

CARE PLANNING

Information gathered from the nutritional assessment and current dietary standards of

practice are used to develop an individualized care plan to address the resident’s specific

nutritional concerns and preferences. The care plan must address, to the extent possible,

identified causes of impaired nutritional status, reflect the resident’s personal goals and

preferences, and identify resident-specific interventions and a time frame and parameters

for monitoring. The care plan should be updated as needed, such as when the resident’s

condition changes, goals are met, interventions are determined to be ineffective, or as

new causes of nutrition-related problems are identified. If nutritional goals are not

achieved, the care planned interventions must be reevaluated for effectiveness and

modified as appropriate.

Examples of goals may include, but are not limited to:

• A target weight range.

• Desired fluid intake.

• The management of an underlying medical condition (e.g. diabetes, kidney

disease, wound healing, heart failure, or infection.)

• The prevention of unintended weight loss or gain.

Weight stability, rather than weight gain, may sometimes be the most pertinent short-term

or long-term objective for the nutritionally at-risk or compromised resident. After an

acute illness or as part of an advanced or end-stage medical condition, the resident’s

weight and other nutritional parameters may not return to previous levels and may

stabilize at a lower level, sometimes indefinitely.

NOTE: There should be a documented clinical basis for any conclusion that nutritional

status or significant weight change are unlikely to stabilize or improve (e.g., physician’s

documentation as to why weight loss is medically unavoidable).

The resident and/or the resident’s representative’s involvement in the development of the

care plan helps to ensure it is individualized and meets their personal goals and

preferences. See F551, Resident Representative; F553, Right to Participate in Care

Planning, or §483.21, Comprehensive Resident-Centered Care Plans, for additional

guidance.

When preferences are not specified in an advanced directive, decisions related to the

possible provision of supplemental or artificial nutrition should be made in conjunction

with the resident, the resident’s family, and/or representative in accordance with state

law, taking into account relevant considerations such as condition, prognosis, and the

resident’s known values and choices.

NOTE: The presence of a “Do Not Resuscitate” (DNR) order does not by itself indicate

that the resident is declining other appropriate treatment and services. It only

indicates that the resident has chosen not to be resuscitated if cardiopulmonary

functions cease.

INTERVENTIONS

Interventions related to a resident’s nutritional status must be individualized to address

the specific needs of the resident. Examples of care plan development considerations can

include, but are not limited to:

Diet Liberalization: Based on the resident’s assessment, it could be beneficial to

minimize restrictions, such as therapeutic or mechanically altered diets, and provide

preferred foods before using supplementation. However, it is the responsibility of the

facility to:

• Talk with the resident, their family and representative (whenever possible) and

provide information pertaining to the risks and benefits of a liberalized diet;

• Work with the resident’s physician and other nursing home professionals (dietary

manager, nurses, speech therapists, etc.), using the care planning process, to

determine the best plan for the resident; and

• Accommodate the resident’s needs, preferences, and goals.

Weight-Related Interventions: For at risk residents, the care plan should include

nutritional interventions to address underlying risks and causes of unplanned weight loss

or unplanned weight gain, based on the comprehensive or any subsequent nutritional

assessment. The development of these interventions should involve the resident and/or

the resident representative to ensure the resident’s needs, preferences and goals are

accommodated.

Environmental Factors: Appetite is often enhanced by the appealing aroma, flavor,

form, and appearance of food. Resident-specific facility practices that may help improve

intake include providing a pleasant dining experience (e.g., flexible dining environments,

styles and schedules), providing meals that are palatable, attractive and nutritious (e.g.,

prepare food with seasonings, serve food at proper temperatures, etc.), and making sure

that the environment where residents eat (e.g., dining room and/or resident’s room) is

conducive to dining.

Disease Processes: A resident’s clinical condition may have a significant impact on the

types of interventions considered. The facility is responsible for identifying relevant

diagnoses (e.g. wound healing, anorexia, end-of-life, etc.) and appropriate interventions

to address specific needs, as applicable.

Functional Factors: These include resident conditions that interfere with their ability to

physically perform the task of eating or drinking adequately, such as the ability to use

one’s hands, vision, chewing and swallowing capabilities, or the ability to reposition

one’s self at the table. The underlying causes should be assessed to identify which

interventions may be most effective. For example, a resident may experience a decline in

his or her ability to chew food. If the underlying cause is poorly fitting dentures that are

causing pain or are loose in the mouth, the intervention of modifying the food texture

would not address the primary cause.

The interventions used to address functional factors will depend on the resident’s specific

areas of concern and can vary. Some interventions used to address functional factors

include using specialized dishes and utensils, having eye glasses or hearing aids in use,

ensuring dentures are securely placed, participating in a restorative eating program, or

having direct assistance by staff or family. Other interventions may include ensuring food

and drinks are readily accessible and in close physical proximity to individuals with

mobility impairments.

Modification of food and fluid consistency may be an appropriate intervention, however

it may unnecessarily decrease quality of life and impair nutritional status by affecting

appetite and reducing intake.

4 Many factors influence whether a swallowing abnormality

eventually results in clinically significant complications, such as aspiration pneumonia.

Identification of a swallowing abnormality alone does not necessarily warrant dietary

restrictions or food texture modifications. No interventions consistently prevent

aspiration and no tests consistently predict who will develop aspiration pneumonia.5 For

example, tube feeding may be associated with aspiration, and is not necessarily a

desirable alternative to allowing oral intake, even if some swallowing abnormalities are

present.

6,7

Medications: Medications may be helpful in improving a resident’s nutritional status.

Some ways medications may help a resident can be to increase appetite, reduce acid

reflux, or reduce nausea. Some medications may have the unintended effect of impairing

a resident’s nutritional or hydration status and the resident may experience a lack of

appetite, nausea, dry mouth, or other unintended effects. Interventions may be required to

address these. For example, a resident may require frequent sips of a drink during a meal

if they experience dry mouth. It may also be appropriate to consider changing, stopping,

or reducing the doses of those medications as appropriate. For additional guidance related

to medications, refer to §483.45(d), F757, Unnecessary Drugs, or §483.45(e), F758,

Psychotropic Drugs.

Food Intake: Improving intake with wholesome foods is generally preferable to adding

nutritional supplements. However, if the resident is not able to eat recommended

portions at meal times, to consume between-meal snacks/nourishments, or if he/she

prefers the nutritional supplement, supplements may be tried to increase calorie and

nutrient intake. Taking a nutritional supplement during medication administration may

also increase caloric intake without reducing the resident’s appetite at mealtime.

Examples of other interventions to improve food intake include:

• Fortification of foods (e.g., adding protein, fat, and/or carbohydrate to foods such

as hot cereal, mashed potatoes, casseroles, and desserts);

• Offering smaller, more frequent meals;

• Providing between-meal snacks or nourishments; or

• Increasing the portion sizes of a resident’s favorite foods and meals; and

providing nutritional supplements.

To date, the evidence is limited about benefits from appetite stimulants. While their use

may be appropriate in specific circumstances, they are not a substitute for appropriate

investigation of potentially modifiable risk factors and underlying causes of weight loss.

Maintaining Fluid and Electrolyte Balance: Poor fluid intake, abnormal lab values for

electrolytes, some medications, and resident conditions may all affect a resident’s

fluid/electrolyte balance. Offering a variety of fluids during and between meals, assisting

residents with drinking, keeping beverages available and within reach, and evaluating

medications for placing a resident at risk for dehydration are examples of interventions

that may be used to improve a resident’s fluid balance. Alternate fluids, such as

popsicles, gelatin, and ice cream, may also be offered. For some residents, a fluid

restriction may be required to address conditions, such as edema or congestive heart

failure, and may place them at greater risk for dehydration.

Feeding Tubes: Feeding tubes may be used to provide adequate nutrition to a resident

who is not able to achieve it with other interventions. The liquid nourishment that is

administered through a feeding tube is complete nourishment that must be prescribed to

meet all the nutritional needs of the resident. Use F692 to guide the investigation into

concerns regarding the nutritional adequacy of the prescribed formula. Concerns

regarding care of feeding tubes, and/or complications related to their use should be

investigated at F693.

NOTE: For residents with end stage dementia, the use of tube feeding does not

necessarily extend life, prevent aspiration pneumonia, improve function or limit

suffering. For additional guidance related to feeding tubes, see 42 CFR §483.25(g)(4)-(5),

F693, Enteral Nutrition.

Total Parenteral Nutrition (TPN): TPN is a method of providing nutrition where a

liquid formula is given into a vein through an intravenous catheter (IV) to provide most

of the nutrients a resident needs. This method is used when a resident cannot or should

not eat or drink by mouth. A resident with TPN may require additional monitoring, such

as more frequent weights, to ensure the treatment is effective. For additional guidance,

see 42 CFR §483.25(h), F694, Parenteral Fluids.

NOTE: If the resident and/or the resident’s representative exercises his/her right to

choose and declines interventions designed to improve or maintain their

nutritional or hydration status, the facility is responsible for discussing the risks

and benefits associated with that decision and offer alternatives, as appropriate.

The comprehensive care plan should describe any interventions offered, but

declined by the resident or resident’s representative. See F656, Comprehensive

Care Plans.

MONITORING

On-going monitoring of care planned interventions is necessary for all residents. On-going monitoring should include, but is not limited to:

• Interviewing the resident and/or resident representative to determine if their

personal goals and preferences are being met.

• Directly observing the resident.

• Interviewing direct care staff to gain information about the resident, the

interventions currently in place, what their responsibilities are for reporting on

these interventions, and possible suggestions for changes, if necessary.

• Reviewing the resident-specific factors identified as part of the comprehensive

resident assessment and any supplemental nutrition assessment, as needed to

determine if they are still relevant or if new concerns have emerged, such as new

diagnoses or medications.

• Evaluating the care plan to determine if current interventions are being

implemented and are effective. This can include reviewing weight records, meal

monitors, intake and output logs, nurses’ notes, lab values, and physician or

dietitian assessments.

INVESTIGATIVE PROTOCOL

Use the Nutrition and Hydration Critical Element (CE) Pathway, for the concerns being

evaluated, along with the above interpretive guidelines when determining if the facility

provides the necessary care and services to meet the resident’s needs.

Summary of Procedure

Briefly review the most recent comprehensive assessments, comprehensive care plan and

orders to determine whether the facility has assessed, identified and addressed as

appropriate, the resident’s nutritional and hydration needs. This information will guide

observations and interviews to be made in order to corroborate concerns identified.

NOTE: In addition to actual or potential physical harm, always observe for visual cues

of psychosocial distress and consider whether psychosocial harm has occurred when

determining severity level (See guidance on Severity and Scope Levels and Psychosocial

Outcome Severity Guide located in the Survey Resources zip file located at

https://www.cms.gov/medicare/provider-enrollment-and-

certification/guidanceforlawsandregulations/nursing-homes).

KEY ELEMENTS OF NONCOMPLIANCE

To cite deficient practice at F692, the surveyor's investigation will generally show that

the facility failed to do one or more of the following:

• Accurately and consistently assess a resident’s nutritional status on admission and

as needed thereafter;

• Identify a resident at nutritional risk and address risk factors for impaired

nutritional status, to the extent possible;

• Identify, implement, monitor, and modify interventions (as appropriate),

consistent with the resident’s assessed needs, choices, preferences, goals, and

current professional standards of practice, to maintain acceptable parameters of

nutritional status;

• Notify the physician as appropriate in evaluating and managing causes of the

resident’s nutritional risks and impaired nutritional status;

• Identify and apply relevant approaches to maintain acceptable parameters of

residents’ nutritional status, including fluids;

• Provide a therapeutic diet when ordered;

• Offer sufficient fluid intake to maintain proper hydration and health.

NOTE: Weight loss, abnormal protein and electrolyte lab values, and dehydration are

not, by themselves, sufficient to support noncompliance at F692. Additionally, a

resident does not need to experience weight loss, abnormal protein levels, D or

dehydration to show noncompliance.

DEFICIENCY CATEGORIZATION

Examples of Severity Level 4 Noncompliance: Immediate Jeopardy to Resident

Health or Safety include but are not limited to:

• Repeated, systemic failure to assess and address a resident’s nutritional status and

to implement pertinent interventions based on such an assessment resulted in

continued significant or severe weight loss and functional decline;

Repeated failure to assist a resident who required assistance with meals and drink

resulted in or made likely the development of life-threatening symptom(s), or the

development or continuation of severely impaired nutritional status;

• Dietary restrictions or downgraded diet textures, such as mechanical soft or

pureed textures, were provided by the facility against the resident’s expressed

preferences and resulted in substantial and ongoing decline in food intake

resulting in significant or severe unplanned weight loss with accompanying

irreversible functional decline to the point where the resident was placed on

Hospice; or

• The failure to provide an ordered potassium restricted therapeutic diet resulted in

evidence of cardiac dysrhythmias or other changes in medical condition due to

hyperkalemia.

Examples of Severity Level 3 Noncompliance: Actual Harm that is not Immediate

Jeopardy includes but are not limited to:

• The failure to revise and/or implement the care plan addressing the resident’s

impaired ability to feed him/herself resulted in significant, not severe, unplanned

weight change and impaired wound healing (not attributable to an underlying

medical condition);

• The failure to identify a decrease in food intake, which resulted in a significant,

unintended weight loss from declining food and fluids, which resulted in the

resident becoming weakened and unable to participate in activities of daily living;

• The failure to assess the relative risks and benefits of restricting or downgrading

diet and food consistency or to accommodate a resident’s choice to accept the

related risk resulted in declining food/fluid intake and significant weight loss;

• The failure to accommodate documented resident food dislikes and preferences

resulted in poor food/fluid intake and a decline in function; or

• The failure to provide a gluten-free diet (one free of wheat, barley, and rye

products) as ordered for a resident with known celiac disease (damage to the

small intestine related to gluten allergy) resulted in the resident developing

persistent gastrointestinal symptoms including significant, not severe, weight loss,

chronic diarrhea, and occasional vomiting.

Examples of Severity Level 2 Noncompliance: No Actual Harm with Potential for

More Than Minimal Harm that is Not Immediate Jeopardy include but are not

limited to:

• Failure to obtain accurate weight(s) and to verify weight(s) as needed;

• The facility’s intermittent failure to provide required assistance with eating

resulted in poor intake, however, the resident met identified weight goals;

• Failure to provide additional nourishment when ordered for a resident, however,

the resident did not experience significant or severe weight loss; and

• Failure to provide a prescribed sodium-restricted therapeutic diet (unless declined

by the resident or the resident’s representative or not followed by the resident);

however, the resident did not experience medical complications such as heart

failure related to sodium excess.

Severity Level 1: No Actual Harm with Potential for Minimal Harm

• The failure of the facility to provide appropriate care and services to maintain

acceptable parameters of nutritional status, which includes hydration, and

minimize negative outcomes places residents at risk for more than minimal harm.

Therefore, Severity Level 1 does not apply for this regulatory requirement.

POTENTIAL TAGS FOR ADDITIONAL INVESTIGATION

During the investigation of F692, the surveyor may have determined that concerns may

also be present with related outcome, process and/or structure requirements. The

surveyor is cautioned to investigate these related requirements before determining

whether non-compliance may be present. Some examples of related requirements that

should be considered include §483.20 Resident Assessment, §483.21 Comprehensive

Person-Centered Care Planning, §483.24 Quality of Life, §483.30 Physician Services,

§483.35 Nursing Services, §483.60 Food and Nutrition Services, §483.70 Administration,

and §483.75 QAPI.

1 Walker, G. (Ed.) (2005). Pocket Guide for Nutrition Assessment. Chicago, IL:

Consulting Dietitians in Healthcare Facilities.

2 Thomas D.R., Tariq, S.H., Makhdomm S., Haddad R., & Moinuddin

A. (2003). Physician misdiagnosis of dehydration in older adults. Journal of the

American Medical Directors Association, 4(5), 251–254.

3 Covinsky, K.E., Covinsky, M.H., Palmer, R.M., & Sehgal, A.R. (2002). Serum

albumin concentration and clinical assessments of nutritional status in hospitalized older

people: Different sides of different coins? Journal of the American Geriatrics Society,

50(4) 631- 637.

4Groher, M.E. & McKaig, T.N. (1995). Dysphagia and dietary levels in skilled nursing

facilities. Journal of the American Geriatric Society, 43(5), 528-532.

5 Loeb, M.B., Becker, M., Eady, A., & Walker-Dilks, C. (2003). Interventions to prevent

aspiration pneumonia in older adults: A systematic review. Journal of the American

Geriatrics Society, 51(7), 1018-1022.

6 Feinberg, M.J., Knebl, J., & Tully, J. (1996). Prandial aspiration and pneumonia in an

elderly population followed over 3 years. Dysphagia, 11(2), 104-109.

7 Mamun, K., & Lim, J. (2005). Role of nasogastric tube in preventing aspiration

pneumonia in patients with dysphagia. Singapore Medical Journal, 46(11), 627-631.