Other·December 21, 2023

Re-certification Survey on 06/04/2023 Event ID E0ZW11. Select the Violated Requirement(s): 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. On 06/04/23 through 06/09/23, a recertification survey was conducted at the facility. The facility failed to identify, monitor, and intervene for the weight loss of seven (7) pounds (lbs.), 5.6% in one month, for one of two sampled patients (Patient 8). This failure resulted in Patient 8 not receiving an assessment and intervention to prevent further weight loss. Patient 8 had a severe weight loss of 10.31% over a period of three (3) months. Patient 8 was at risk for continued weight loss, weakness, malnutrition (not getting proper/enough nutrients for the body) such as protein calorie malnutrition and decline in functional status. Findings: Patient 8 was readmitted on 12/20/22 with diagnoses including Epilepsy (seizures) and Dysphagia (difficulty or discomfort in swallowing food or liquids), Major Depressive Disorder (characterized by persistent feelings of sadness, hopelessness, and worthlessness). During a review of Patient 8's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 04/14/23, the MDS indicated Patient 8's Brief Interview for Mental Status (BIMS- a mental status exam) was three (3) out of 15, indicating severely impaired mental status. The MDS assessment also indicated Patient 8 required one staff's extensive assist with eating. During a concurrent interview and record review on 06/07/23, at 3:09 p.m., with Registered Dietician (RD) 1, Patient 8's electronic medical record for Patient's Vital Stats" was reviewed. The record indicated Patient 8's weight on 04/03/23 was 125.4 and on 05/07/23 weight was 118.4 lbs. RD 1 stated Patient 8 lost a total of eight (8) lbs./5.6% in one month, which was a significant weight loss. RD 1 stated she was not aware of Patient 8's significant weight loss as she only utilized a "Weight Binder" to track patient weights. During a concurrent interview and record review on 06/07/23, at 3:15 p.m. with RD 1, at nursing station, a Weight Binder with a document labeled "Monthly Weight Grid-June 2022 through May 2023" was reviewed. The document indicated Patient 8's weight was not entered for the month of May 2023 and June 2023. RD 1 stated Patient 8 should have been on a "fortified diet (more nutrients added to the diet)" with additional 600 calories since 05/07/23 to ensure no more further weight loss specially because Patient 8 had a history of weight fluctuations. RD 1 also stated Patient 8's physician and the Responsible Party should have been made aware of Patent 8's significant loss. RD 1 stated Patient 8 should have been on a "fortified diet (more nutrients added to the diet)" with additional 600 calories since 05/07/23 to ensure no more further weight loss specially because Patient 8 had a history of weight fluctuations. RD 1 also stated Patient 8's physician and the Responsible Party should have been made aware of Patient 8's significant loss. During a concurrent interview and record review on 06/07/23, at 3:20 p.m., Patient 8's "Quarterly Nutritional Assessment" dated 5/22/23 reviewed. The assessment indicated "Noted weight loss this month, recommended to reweigh, goal to maintain 118 pounds". RD 1 stated she did not recall if she asked Restorative Nursing Aide (RNA- staff responsible to weigh patients) to reweigh Patient 8 on or after 05/22/23. During a record review on 6/8/23, at 10:15 a.m., with RD 1, Patient 8's electronic health record for weights was reviewed. The record indicated Patient 8's weight on 6/7/23 was 116 lbs. During an interview on 6/08/23, at 2:03 p.m., with RD 1, RD1 stated Patient 8 was expected to stay in weight range of 120-130 lbs. Patient 8 weight was below 120 and she was not on a physician prescribed weight loss regimen. During a concurrent interview and record review on 06/08/23, at 2:15 p.m., with Licensed Vocational Nurse (LVN) 2, Patient 8's electronic medical record including progress notes, weights, weekly summary from 05/01/2023 till 06/08/2023 reviewed. LVN 2 stated Patient 8 was sleepier last week and is eating more in her room. LVN 2 stated she notified Patient 8's physician about her increased sleepiness and decreased meal intake couple days ago but unable to find any documentation regarding her communication and interventions. During an interview on 6/9/23, at 10:44 a.m., with Director of Nursing (DON), DON stated unaddressed weight loss of Patient 8 placed her at risk for continued weight loss, weakness, malnutrition (not getting proper/enough nutrients for the body) such as protein calorie malnutrition and decline in functional status. During a concurrent interview and record review on 6/9/23, at 11:15 a.m., with RD 1, the facility's Policy, and Procedure(P&P) titled "Fortification of Food: Increasing Calories and/or Protein in the Diet", dated 2018, was reviewed. The P&P indicated "The enrichment of foods will be done on an individual basis for the patient who cannot consume adequate amounts of calories and/or protein to sustain their weight or nutrition status." RD 1 stated facility used 1/2 a ladle scoop of margarine in two food items to meet the extra 600 calories per day for fortification of patient's meals. RD 1 stated each 1/2 ladle of margarine provided extra 300 calories. During a review of the facility's Policy and Procedures (P&P) titled, "RDs For Health Care, INC. Weight Change Protocol" dated 2018, the P&P indicated, "Early identification of weight problem and possible cause(s) can minimize complications. Assessment of patients experiencing weight changes should be completed in a timely manner. Patients will be weighed monthly and weekly for those newly admitted and those deemed to be at high risk for weight changes according to the facility's policies. Variances are calculated from monthly and weekly weights that are obtained by the facility staff. Patients who experience significant changes in weight or insidious weight loss will be assessed by RD. The following criteria define significant or insidious weight changes: Unplanned weight loss trend that has occurred 2 times or more. This can refer to weekly or monthly weights, pounds weight loss or gain in 1 week or as facility policy states, pounds weight loss or gain in 1 month, 5.0% weight loss or gain in 1 month, 7.5% weight loss or gain in 3 months, 10% weight loss or gain in 6 months". During a review of facility's Policy and Procedure (P&P) titled, "Nutrition (Impaired)/Unplanned Weight Loss-Clinical Protocol", dated 2017, the P&P indicated, "The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time. The staff and physician will define the individual's current nutritional status (weight, food/fluid intake, and pertinent laboratory values) and identify individuals with weight loss or gain, anorexia, and significant risk for impaired nutrition. The staff will report to the physician significant weight losses or gains or any abrupt or persistent change from baseline appetite or food intake". This violation had a direct or immediate relationship to the health, safety, or security of Patient 8. In violation of the above standards, the facility failed to identify, monitor, and intervene for Patients 8's weight loss of seven (7) pounds (lbs.), 5.6% in one month. This failure resulted in Patient 8 not receiving an assessment and intervention to prevent further weight loss. Patient 8 had a severe weight loss of 10.31% over a period of three (3) months. Patient 8 was at risk for continued weight loss, weakness, malnutrition (not getting proper/enough nutrients for the body) such as protein calorie malnutrition and decline in functional status.