MARKSVILLE, LA - A state health inspection at Colonial Nursing and Rehabilitation Center revealed critical failures in nutrition management, including a 19-pound weight loss in one resident that went without proper dietitian evaluation despite documented referral requirements.
Critical Weight Loss Management Failure
Colonial Nursing and Rehabilitation Center demonstrated significant deficiencies in managing a resident's severe nutritional decline, according to inspection findings from May 29, 2025. Resident #8 lost 19 pounds within a single month, dropping from 181 pounds to 162 pounds between April 21 and May 19, 2025, while receiving tube feeding nutrition.
The resident's dietary admission assessments documented the progressive weight loss across multiple weeks. On April 21, the resident weighed 181 pounds and was receiving Diabetisource 1.5 formula at 50 milliliters per hour through a feeding tube. By April 30, the weight had decreased to 175 pounds, and by May 19, it had fallen further to 162 pounds. Despite these alarming changes, dietary management notes repeatedly stated "Recommended continue with same plan of care" without adjustments to address the continuing weight loss.
This represented a 10.5% body weight loss in just 28 days - far exceeding the 5% threshold that typically triggers immediate intervention in clinical settings. Such rapid weight loss in tube-fed patients indicates either inadequate caloric provision, absorption problems, or underlying metabolic issues requiring urgent assessment.
Breakdown in Professional Communication
The facility's Director of Nursing (DON) documented awareness of the weight loss problem in a weight change evaluation form, noting the resident had recently returned from hospitalization on April 30, 2025, following aspiration pneumonia treatment and new feeding tube placement. The DON's notes indicated "NPO status" (nothing by mouth) during hospitalization and documented plans to "refer to RD for evaluation" with confirmation that the "referral to RD for review" was completed.
However, investigation revealed this critical referral never reached the registered dietitian. During a telephone interview on May 29, the facility's contracted registered dietitian confirmed she "did not receive any evaluation request or referrals regarding Resident #8's significant weight loss from the facility upon his return from the hospital." The dietitian explained she visited the facility once or twice monthly and relied on email notifications from staff to identify residents requiring assessment.
When questioned, the DON maintained she had sent the referral and requested evaluation but could not produce any documentation proving the communication occurred. This breakdown in the referral system left a vulnerable resident without specialized nutritional intervention during a critical recovery period.
Medical Implications of Unaddressed Weight Loss
Significant weight loss in nursing home residents receiving tube feeding carries serious health consequences. When a resident loses 10% or more body weight within a month, the risk of pressure injuries increases substantially due to loss of protective tissue padding. The immune system becomes compromised, making residents more susceptible to infections - particularly concerning for someone recovering from aspiration pneumonia.
Tube-fed residents require careful monitoring because weight loss despite controlled nutrition delivery often signals underlying complications. Malabsorption, increased metabolic demands from infection or illness, or inadequate formula volume can all contribute to nutritional decline. Standard protocols require immediate dietitian consultation when weight loss exceeds 5% in one month or 7.5% in three months.
The resident's formula - Diabetisource 1.5 at 50 milliliters per hour - provides approximately 1,800 calories daily when administered continuously. For a 181-pound individual, this might meet basic needs, but stress from recent hospitalization and pneumonia recovery typically increases caloric requirements by 25-50%. Without dietitian evaluation, these increased needs went unaddressed.
Industry Standards and Protocol Failures
Federal regulations require nursing homes to ensure residents maintain acceptable nutritional status unless clinical conditions make this impossible. Facilities must employ sufficient staff with appropriate competencies and skill sets, including access to registered dietitian services. When significant weight changes occur, immediate assessment and intervention protocols should activate automatically.
Best practices in long-term care nutrition management include weekly weights for high-risk residents, immediate dietitian notification for weight changes exceeding 5%, and documented communication systems ensuring referrals reach appropriate professionals. Electronic health records typically include alert systems flagging significant weight changes and tracking referral completion.
The facility's system relied on email communication between nursing staff and the visiting dietitian without apparent confirmation protocols or follow-up mechanisms. This created a critical gap where urgent referrals could fail without detection. The dietary manager's repeated notes to "continue with same plan of care" despite progressive weight loss suggest inadequate review processes or clinical oversight.
Additional Issues Identified
Beyond the primary nutritional management failures, the inspection identified related documentation deficiencies. The facility lacked evidence of systematic weight monitoring protocols, interdisciplinary communication procedures, and quality assurance measures to prevent similar incidents. The absence of documented dietitian evaluation following the resident's hospitalization and feeding tube placement represented additional regulatory violations.
The inspection findings classified these deficiencies as affecting "some" residents with potential for actual harm, indicating systemic issues potentially impacting other residents with nutritional risks. The facility's inability to produce requested documentation during the survey suggested broader record-keeping and communication problems requiring comprehensive correction.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Colonial Nursing Home from 2025-05-29 including all violations, facility responses, and corrective action plans.
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