Other·October 23, 2023

F692 - G

F 692 CFR 483.25(g) Assisted nutrition and hydration. (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- (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; (2) Is offered sufficient fluid intake to maintain proper hydration and health; (3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet. During a recertification survey conducted at the facility from 8/28/23 through 9/1/23 it was determined that the facility failed to provide nutritious vegetarian meals (foods that do not contain meat, but only fruits, vegetables, and dairy products) to meet nutritional needs for one of seven sampled patients (Patient 16). Facility did not recognize, intervene and/ or evaluate Patient 16's 23 pounds (lbs.), a significant amount of weight loss during a six-month period. Patient 16 was admitted to the facility on 04/20/20 with diagnoses including but not limited to Hypertension (high blood pressure), Renal Insufficiency (poor kidney function), Diabetes Mellitus (a disease characterized by elevated levels of blood glucose), Hyperlipidemia (high concentration of fats in the blood) and Depression (mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Patient 16's "Minimum Data Set (MDS) - Version 3.0 Resident Assessment and Care Screening Nursing Home Quarterly (NQ) Item Set" dated 7/11/23, the MDS assessment indicated, Resident 16's Brief Interview for Mental Status (BIMS) was 15 out of 15, indicating intact cognitive status. The MDS also indicated Resident 16 required supervision with eating. During an observation and interview on 8/28/23 at 12:09 p.m., with Patient 16, in Patient 16's room, Patient 16 was lying in bed awake. Patient 16 stated, she was a vegetarian and facility served her foods such as mashed potatoes, mashed sweet potatoes, yogurt, ice cream and milk. Patient 16 stated, she sometimes had lentil soup prepared and brought to her by a family member. Patient 16 stated, she would like more variety of Indian style vegetarian foods. Patient 16 stated, she recently had a few bottom teeth extracted and ate soft foods. Patient 16 stated, the facility stored her uneaten food brought from home, but "would not" reheat the leftovers. Patient 16 stated, she had lost about 25 lbs. in the last few months. Patient 16 had a clear, plastic, gallon sized Ziplock bag with two (2) packs of Goya chocolate maria cookies and two (2) packs of Goya golden maria cookies in the bed next to her. Patient 16 stated, facility staff brought her these cookies. During a concurrent interview and record review on 8/31/23 at 11:22 a.m. with the Minimum Data Set Coordinator (MDSC), Patient 16's electronic medical record for "Weights and Vitals" was reviewed. The record indicated Patient 16's weight on 2/1/23, 8/2/23 and 8/17/23 was 227 lbs., 204 lbs., and 199 lbs. respectively indicating a significant weight loss of 28 lbs. The MDSC stated, Patient 16 was overweight and "is happy with the weight loss". The MDSC stated, Patient 16 had a few teeth extracted in 7/2023, and was in process of getting new dentures. During an interview on 8/31/23 at 11:46 a.m. with the ADON, ADON stated, the Nursing Assistants weighed the patients and notified her about weight variance. The ADON stated, facility then had an Interdisciplinary team (IDT-team members from different departments who work together to resolve patient care problems) meeting to review patients' plan of care. The ADON stated, RD and Activities Director (ACT) were part of the weight meeting. The ADON stated, Patient 16 was a strict vegetarian, so the "diet options were limited" for her at the facility. The ADON stated, she was aware of Patient 16's weight loss and the RD had made recommendations to monitor Patient 16's Hemoglobin A1c (test that shows what a patient's average blood glucose level was over a period of two to three months) on a quarterly basis. The ADON stated, there were no other labs. During a concurrent observation and interview with Certified Nursing Assistant (CNA) 4 on 8/31/23 at 12:18 p.m., in the hallway outside of Patient 16's room, Patient 16's lunch tray was observed. On Patient 16's tray was 1/3 cup (c) of white rice, 1/3 c. of mashed potatoes with gravy, 1/2 c. of herbed green beans, two (2) wheat rolls, 1/2 c. of chopped watermelon pieces and one 4-oz glass of milk. During a follow up observation and interview with Patient 16 on 9/01/23 at 7:09 a.m., Patient 16's breakfast tray was observed. On Patient 16's breakfast tray was two slices of brown bread, one cup of oatmeal, one 4-oz cup of coffee and one 4-oz cup of cold milk. Patient 16 stated, she was going to eat only oatmeal with milk and coffee; because she was not fond of bread and the facility staff knew about that. Patient 16 stated, she also did not eat lunch served to her on 8/31/23. Patient 16 stated, she felt "weak" and had no energy on a consistent basis. Patient 16 stated, it has been going on for months. Patient 16 stated, she would like to eat Indian vegetarian home food. Patient 16 stated, she was about to fall the other day after her shower because she was feeling so weak. Patient 16 stated, she ate crackers and cookies all day long to keep herself full. Patient 16 stated, she had lost interest in watching TV and checking messages on her phone. Patient 16 stated, she was just lying in the bed for the most part of the day every day. Patient 16 stated, she was "not happy" about her weight loss. During an observation in Patient 16's room on 9/01/23 at 9:01 a.m. with CNA 4, the following items were observed on Patient 16's beside nightstand and overbed tray: one 8-oz plastic container of Khari Biscuits, one 12.3 oz box of Papadi chickpea flour crisps, 12-1/2 oz bags of chips of different varieties including nacho cheese flavored Doritos, Cheetos crunchy and Lays potato chips, 2 packs of Goya chocolate maria flavor cookies, 2 packs of Goya golden maria flavor cookies and three 1-oz package of Chips Ahoy miniature chocolate chip cookies. During a telephone interview with the RD on 8/31/23 at 1:16 p.m., RD stated, she had been following Patient 16's weight variance for a long time. RD stated, Patient 16 was not on a physician prescribed weight loss regimen (the process of losing weight with the help and guidance of a healthcare professional). RD stated, Patient 16 preferred an Indian vegetarian diet and "it was hard to know" if Patient 16 was eating enough protein because Patient 16 had a lot of snacks at the bedside. During a review of Patient 16's nutritional care assessments titled "Registered Dietitian Assessment" dated 1/12/23, 4/13/23, and 7/19/23, the nutritional assessment indicated, facility provided 1900 Kilocalories (kcal) calories, 96 grams (gm) of protein while she required 1750-2100 kcal and 70-84 gm of protein every day...patient has many containers of food at her bedside from outside sources"...nutritional goal was to "slow weight loss"... "continue diet as ordered"... perform "appropriate labs as ordered" without any clear indication of what were the appropriate labs for Patient 16. The assessment dated 7/19/23 also indicated, Patient 16's needs weren't always met with current diet and intake", however there was no indication of change in plan of care. During a concurrent interview and record review with the Dietary Supervisor (DS) on 9/01/23 at 10:38 a.m., in facility's kitchen, facility's cooks spreadsheet document titled, "Summer Menus" for the week of 6/5/23 was reviewed. The DS stated she and her staff, including Cooks followed the same Summer Menus sheets to prepare and plate the portion size of foods for all residents who consumed food prepared in facility's kitchen even during the week of 8/28/23. The DS stated the document showed the menu for residents who consumed the following types of diets: 1. Regular, 2. Mechanical soft (foods that break apart without a knife designed for patients who have trouble chewing or swallowing), 3. Pureed (foods have a soft and pudding-like consistency), 4. Dysphagia Mechanical (for people who have trouble swallowing), 4. Two gram Sodium (low salt) 5. Controlled Carbohydrate (CCHO-low carbohydrate) and quantity for Small, Regular, and large portions for above mentioned types of diets. The spreadsheet did not have Menus for "Vegetarian dishes" and/or their portion sizes. During an interview with the DS on 9/1/23 at 10:45 a.m., in DS office, the DS stated, she was unable to find written vegetarian options available at the facility. DS stated, the RD was responsible to review and approve each menu each month however, she was unable to provide a copy of "any" signed and approved menus. DS stated, the facility substituted meat items for vegetarian residents with veggie nuggets, veggie patties, tofu, yogurt, lentils, and cheese. During an observation and interview on 9/1/23 at 10:55 a.m., in facility's kitchen, with DS, three packs of 14-Ounces (Oz.) Tofu was stored in the Walk-in refrigerator, a large cardboard box with frozen Veggie patties on the kitchen counter and lentils/grains were stored in dry storage area. There was no evidence of availability of Veggie nuggets, and/ or Cheese. The DS stated, "we don't cook "Paneer" (the Indian style Cheese). The DS stated, at times, the facility prepared "Spinach and Tofu" and Lentil Soup for vegetarian residents. The DS was unable to state how frequently did the facility serve Spinach-Tofu and Lentil Soup to Resident 16, and if there were more dishes available to meet her protein, fat and carbohydrate needs. During an interview and record review on 9/1/23 at 11:05 a.m., in facility's kitchen, with DS and Cook 1, two binders titled "Recipe Book #1" and "Summer Recipe Book" were reviewed. The DS stated, she was unable to find a recipe on how to make the lentil soup, tofu and/ or any vegetarian dish. The DS stated, her staff, including Cook 1 "just knew" how to make certain Vegetarian foods. Cook 1 confirmed she never followed a recipe to cook Vegetarian meals. During a telephone interview with MD 2 on 9/01/23 at 11:07 a.m., MD 2 stated, he was aware of Patient 16's weight loss however she was "not on a physician prescribed weight loss regimen". MD 2 stated, he was under the impression that facility had a vegetarian menu to meet Patient 16's nutritional needs and was unaware the facility actually did not have a vegetarian menu. MD 2 also stated he relied on the RD to intervene for Patient 16's weight loss and did not know that Patient 16's plan of care from 6 months ago was not changed/updated since Patient 16 began losing weight. During an interview with LVN 14 on 8/31/23 at 12:16 p.m. in the hallway outside of Patient 16's room, LVN 14 stated, facility staff could not reheat food brought from home because the staff did not have a food thermometer available at the facility to check the temperature of the reheated food. During an interview with ACT on 9/01/23 at 9:20 a.m., ACT stated Patient 16 "has not seemed like herself lately", "she was more energetic in the past", "is now less energetic and has been withdrawn". During an interview with Restorative Nursing Assistant (RNA) 1 on 9/01/23 and 9:28 a.m., RNA 1 stated, she worked with Patient 16 for range of motion exercises. RNA 1 stated, she observed a decline in her health; and stated, "she seems different" over the past one to two months. During a record review of Patient 16's Nutrition/Hydration status Care Plan dated 4/7/20, the care plan indicated, Patient 16 had an alteration in nutritional status related to therapeutic diet, hypertension, hyperlipidemia, chronic kidney disease, vitamin B12 deficiency... The care plan indicated, the goal for Resident 16 was to not have a significant weight loss/gain...The care plan indicated, to provide following interventions: controlled carbohydrate mechanical soft diet, no red meat, poultry, fish or eggs, to monitor/ assess food preferences, monitor labs as ordered, encourage family to bring in favorite foods/ snack, encourage 75% or more of meals, if intake is less than 75%, offer substitutes..." During a review of Patient 16's "Order Summary Report" dated 9/1/23, the "Order Summary Report" indicated, Patient 16's Physician ordered diet was "Controlled Carbohydrate (CCHO-low carbohydrate) diet. Mechanical Soft texture (foods that break apart without a knife designed for patients who have trouble chewing or swallowing). No red meat, poultry, fish, or eggs. Ground food with plain yogurt. During a review of Patient 16's food preference document titled "Food & Nutrition Service Director Nutrition Chart Review and Interview" dated 4/28/23, the document indicated, Patient 16's food preference was "vegetarian", without details of options in vegetarian foods. The document also indicated, Patient 16 disliked meat, fish and eggs. During a review of facility's Policy & Procedure (P&P) titled "RDs for Healthcare, Inc. Weight Change Protocol" dated 2018, P&P indicated, "The RD will assess, nutritionally diagnosis, suggest interventions, monitor and evaluate success of the interventions...Assessment:...Determine if the:...meals sent to patient meet their needs and goals...Interventions:...allow for food preferences (cultural, customary) using selections, foods from home...Evaluation:...The evaluation process is done again if there is another significant weight change. Interventions are changed if not effective". This violation had a direct or immediate relationship to the health, safety or security of Patient 16. Conclusion: In violation of the above cited standards, the facility failed to recognize, intervene and/ or evaluate Patient 16's 23 pounds (lbs.), a significant amount of weight loss during a six-month period. This failure resulted in Patient 16 to lose five (5) more lbs. over the following 2 weeks from first six months, leading to 28 lbs. weight loss in over six months, feeling of weakness, consistent hunger and psychological distress, frequently eating snacks such as chips and cookies. Patient 16 remained at high risk for continued weight loss, malnutrition (not getting proper/enough nutrients for the body), a decline in functional status and further psychological distress. Therefore, the facility failed to provide nutritious vegetarian meals to meet the nutritional needs of Patient 16.