CMS Manual System - Louisiana Department of Health and Hospitals

ecognized standards of practice, or provided clinical justification why they did
not do so; and
Monitored and evaluated the resident‘s response to the interventions; and revised
the approaches as appropriate, or justified the continuation of current approaches.
If not, failure to maintain acceptable parameters of nutritional status is avoidable, cite at
Tag F325.
Noncompliance with Tag F325
After completing the investigative protocol, the survey team must analyze the data to
determine whether noncompliance with the regulation exists. Noncompliance must be
established before determining severity. A clear understanding of the facility‘s
noncompliance with requirements (i.e., deficient practices) is essential to determine how
the deficient practice(s) relates to any actual harm or potential for harm to the resident.
Noncompliance with Tag F325 may include (but is not limited to) one or more of the
following, including failure to:
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, goals, and current 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; and
Provide a therapeutic diet when indicated.
Potential Tags for Additional Investigation
If noncompliance with 42 CFR 483.25(i) has been identified, the survey team may have
determined during the investigation of Tag F325 that concerns may also be present with
related process and/or structure requirements. Examples of related process and/or
structure requirements related to noncompliance with Tag F325 may include the
following:
42 CFR 483.10, Tag F150, Resident Rights
o Determine if the resident‘s preferences related to nutrition and
food intake were considered.