Other·May 3, 2024

Title 22 CCR 72311 (a) (3) (B) (D) (a) Nursing service shall include, but not be limited to, the following: (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. (D) A change in weight of five pounds or more within a 30-day period unless a different stipulation has been stated in writing by the patient's licensed healthcare practitioner acting within the scope of his or her professional licensure. 483.10 (g)(14)(i)(B)Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is- On 2/12/2024 at 10:06 a.m., an unannounced visit was conducted at the facility to investigate a complaint incident regarding Resident 1 losing weight and being sent out to the hospital on 1/15/24. The facility failed to ensure licensed nurse's immediately consulted with resident's physician during a significant change in resident's physical status for one of three sampled residents (Resident 1) when licensed nurses did not immediately notify Resident 1's physician, after Resident 1 experienced a severe unplanned weight loss of 18 pounds (lbs- a unit of measurement) or 9.8% in 28 days; on 12/3/23 Resident 1 weighed 184 (lbs) and on 12/31/23 weighed 166 lbs. Nursing staff obtained weekly weights documenting the rapidly declining weights and did not notify the physician of the change in condition (CIC) in accordance with physician expectations and policy and procedure; and did not conduct an Inter Disciplinary Team (IDT-an interdisciplinary team comprised of professionals from various disciplines who work in collaboration to address a resident with multiple physical and psychological needs) meeting to discuss the CIC. The Registered Dietitian (RD) input orders to fortify (added nutrition) Resident 1's diet on 12/22/23 and Licensed Nurses (LNs) did not implement the orders until 12/28/23. LNs did not call the RP (responsible party) in accordance with the signed Power of Attorney (POA- legal document allowing someone else to act on your behalf) when Resident 1 had a change of condition. As a result of these failures Resident 1's physician was not given the opportunity to determine the cause of the rapid decline in weights and clinical status, a delay in providing nutritional support to Resident 1 and contributed to Resident 1 being found unresponsive on 1/15/24 which required an ambulance transport to a higher level of care to a local acute care hospital (ACH). At the ACH, Resident 1 was immediately treated for high levels of ammonia (waste product processed by liver) in the blood and hepatic encephalopathy (damaged liver that causes temporary worsening of brain function). During a review of Resident 1's "Admission Record" (document containing resident demographic information and medical diagnosis) undated, the admission record indicated Resident 1 was admitted to the facility on 11/29/2023. Resident 1's diagnosis included constipation, hypertension (high blood pressure), and muscle weakness. During a review of Resident 1's "Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive (mental process) and physical function Assessment" dated 12/4/23, indicated Resident 1's Brief Interview for Mental Status (BIMS -assessment of memory and judgment) assessment scored was 11 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, 00-07 indicates severe impairment). The BIMS assessment indicated Resident 1 had moderate cognitive impairment. During a telephone interview on 2/15/24 at 9:36 a.m. with RP, RP stated she became the POA in 12/22/23 and wanted the facility to call her with any changes Resident 1 experienced. RP stated prior to Resident 1 being sent out to the hospital she had voiced her concerns to the LNs that Resident 1 was not responsive, not eating, and was sleeping most of the time. RP stated she had been asking the LNs to do blood work to find the underlying cause of Resident 1's decline. RP stated losing 20 lbs in less than a month was a red flag and the LNs did not act upon her requests. RP stated if the LNs had called her when Resident 1 had a change of condition, she would have instructed them to send Resident 1 to the hospital. During a review of Resident 1's "Advanced Health Care Directive Form (AD)" dated 12/22/23, the "AD" indicated, "...When agents authority becomes effective: My agent's authority becomes effective when my primary physician determines that I am unable to make my own health care decisions unless I make the following box. If I mark this box [box marked], my agent's authority to make health care decisions for me takes effect immediately..." During a telephone interview on 2/14/24 at 3:20 p.m. with Social Services (SS), SS stated Resident 1's Responsible Party (RP) came to the facility on 12/22/23 with a notary (appointed official serving as an impartial witness) to sign the POA. SS stated she was present when the notary and Resident 1's RP were signing the POA. SS stated from 12/22/23, LNs should call the RP for any health-related decisions. During a concurrent telephone interview and record review on 2/16/24 at 10:55 a.m. with RD, Resident 1's "weight review" dated 12/15/23 was reviewed. The "RD weight review" indicated, " ...Wt [Weight] 172 [pounds] ... Wt change: -12 lbs x 1 week ...Res [Resident] continues to tolerate diet as ordered with an excellent PO [by mouth] intake which meets estimated needs ...wt loss is likely r/t [related to] fluid balance shifts. No new RD recommendations ..." RD stated Resident 1 had edema [swelling caused fluid trapped in the body's tissues] and was taking medications to eliminate excess fluids. RD stated the goal was to maintain Resident 1's weight in the 180lb range. During a concurrent telephone interview and record review on 2/16/24 at 11:10 a.m. with RD, Resident 1's "weight review" dated 12/22/23 was reviewed. The "RD weight review" indicated, " ...Wt [Weight] 167 [pounds] ... Wt change: -5 lbs x 1 week ...Res [Resident] continues to tolerate diet as ordered, ... intake is excellent and meets estimated needs ... however, res continues to have wt loss ...Res was happy with wt loss before as it was likely r/t fluid balance shifts, however this further wt loss may be r/t underlying medical conditions ...RD recommends fortified [added nutrition], large portion diet with PBJ [peanut butter jelly] sandwich TID [three times a day] between meals to increase energy intake and minimize risk for further wt loss ...Goal: resident will tolerate diet to meet estimated needs and will have gradual wt gain to maintain 172 +/- 5 lbs ..." RD stated when Resident 1 continued to lose weight and no longer had edema the weight loss became a concern. RD stated LNs should contact the physician when there is a significant weight loss so the physician can order laboratory (labs- facility conducting testing and analysis). RD stated he communicates his recommendations via email to the Director of Nurses (DON), LNs, and MDS. RD stated his expectation was for LNs to implement his recommendations within 48 hours. RD stated his recommendation was not started until 6 days later, the purpose of his recommendation was to increase calories (nutritional value of foods). RD stated increasing calories was intended to minimize tissue loss and decrease the chances of malnutrition (lack of proper nutrition). During a concurrent telephone interview and record review on 2/16/24 at 11:20 a.m. with RD, Resident 1's "weight review" dated 1/2/24 was reviewed. The "RD weight review" indicated, " ...Wt [Weight] 166 [pounds] ... Wt change: -8 lb x 1 week, -18 lbs x 1 month ...skin intact no edema noted. Res continues to tolerate diet as ordered with a good PO intake which meets estimated needs ...Res Is concerned with wt loss and requests high calorie ... To ensure that needs are met ...RD recommends [nutritional drink] 4 oz [ounce-unit of measure] TID to ensure that needs are met and weight is maintained at 166 +/-5lb ..." RD stated he was worried about Resident 1's weight loss and recommended [nutritional drink]. RD stated he did not know why Resident 1 kept losing weight as he was a good eater, but his weight kept declining. RD stated on 1/2/24 was his last assessment of Resident 1. During a telephone interview on 3/4/24 at 1:08 p.m., with RD, RD stated Resident 1 lost a total of 18 lb's from 12/3/23 to 12/31/23 which was 9.8% weight loss. RD stated since admission 11/30/23 to 1/14/24 Resident 1 had 20 lb 11% weight loss. During a concurrent interview and record review on 2/20/24 at 11:04 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 1's "Care Plan (CP)" dated 12/10/23 was reviewed. The "CP" indicated, "...Monitor/record/report to MD [medical doctor] PRN [as needed] ...significant weight loss: 3lbs in 1 week, > [greater than]5% in 1 month ..." LVN 1 stated the purpose of the care plan was for staff to follow interventions created for Resident 1. LVN 1 stated the care plan was not followed because Resident 1 had weight loss since 12/15/23 and the physician was not called until 1/4/24. During a concurrent interview and record review on 2/20/24 at 11:10 a.m. with LVN 1, Resident 1's "Progress Notes (PN)" dated 12/28/23 was reviewed. The "PN" indicated, "RD recommendations fortified large portion diet and PBJ sandwich ...between meals reviewed with MD, order in place ..." LVN 1 stated RD placed the recommendation on 12/22/23 and was not implemented until 12/28/23 (six days after the RD written recommendations). LVN 1 stated the RD's recommendation should be implemented "right away". LVN 1 stated the purpose of the recommendation was to ensure Resident 1 received adequate nutrition. During a concurrent interview and record review on 2/20/24 at 11:20 a.m. with LVN 1, Resident 1's electronic medical record (EMR) for "weights and vitals summary" dated 11/30/23 to 1/14/22 was reviewed. The vital signs weights indicated Resident 1's weights were: 11/30/23 181 lbs 12/3/23 184 lbs 12/10/23 172.0 lbs 12/17/23 167 lbs 12/24/23 174 lbs 12/31/23 166 lbs 1/9/24 163 lbs 1/14/24 161 lbs LVN 1 stated the physician should have been notified of the three pound plus or minus weight change for Resident 1 when it was identified. LVN 1 stated the physician was not notified until 1/4/24. LVN 1 stated the purpose of calling the physician was so he could conduct an assessment and make recommendations. LVN 1 stated there should have been a Change in Condition (CIC) done for Resident 1's weight loss which would have triggered the LN to call the physician but a call was not made to the physician until 1/4/24. During a review of Resident 1's "Progress Notes (PN)" dated 1/4/24, the "PN" indicated, "... weight loss ... meal intake is good ... recently started on [nutritional drink] three times a day ... no edema to exts [extremities] noted ... primary care provider responded ... recommendations: weekly weights ... MD ... in facility and made aware ..." During a concurrent interview and record review on 2/20/24 at 11:30 a.m. with LVN 1, Resident 1's PN dated 1/10/24 was reviewed. The "PN" indicated, "...Resident [RP] in facility ...Per resident OK to talk to her regarding care/medications ...per [RP] she would like [MD] to see resident she expressed concerns: ...over weight loss ...wants labs ...kidney [part of body removing waste] function ...possible underlying causes of weight loss ...unable to reach Dr ...vm [voicemail left] ..." LVN 1 stated Resident 1's RP was concerned and the LN should have called the MD more than once. LVN 1 stated there was no other calls placed to the MD until Resident 1 had a CIC on 1/4/24. LVN 1 stated there were two other MD's and a Nurse Practitioner (NP) that could have been called. LVN 1 stated if it was not documented it was not done. LVN 1 stated the LN should have followed up with the RP's request to prevent delaying interventions the MD may order. During a concurrent interview and record review on 2/20/24 at 11:40 a.m. with LVN 1, Resident 1's "PN" dated 1/12/24 was reviewed. The "PN" indicated, "... change in condition... seems different than usual tired, weak, confused, or drowsy ... at medication pass, resident c/o[complained of] not feeling good, feeling really tired ... Resident refused to go out to hospital for further eval[evaluation]. Refuse to eat breakfast and lunch. Recent weight loss noted ... complains of feeling sleepy ... primary care provider responded... blood tests urinalysis or culture ..." LVN 1 state RP was Residents 1's POA and should have been called when Resident 1 had a CIC and refused to go to the hospital. LVN 1 stated there was no documentation that the RP was called. During a review of Resident 1's "PN" dated 1/13/24, the "PN" indicated, "... received the lab result notified the M/D [Medical Doctor] put the result M/D binder ..." During a review of Resident 1's "PN" dated 1/15/24, the "PN" indicated, "... unresponsive ...CNA [certified nursing assistant] reported that patient was not responding to her. Upon assessment patient was found unresponsive. Eye open blinking tongue sticking out slightly .... MD notified ... may transfer to hospital for further evaluation ..." During a telephone interview on 2/20/24 at 12:49 p.m. with MD, MD stated his expectation was that LNs call and notify him when there is a significant weight change. MD stated he has provided the facility with his cell phone, home phone and office number. MD stated he was the medical director of the facility, and the ultimate goal was to keep residents safe. During a review of Resident 1's General Acute Care Hospital "History and Physical (H&P)" dated 1/15/24, the "H&P" indicated, "... altered mental status ... called [facility name] ... per charge nurse she does not usually take care of patient and so she only has a very limited information ... mentioned that patient reported that he was not feeling good and was feeling tired last few days. She does not have any further information ... also spoke with patients [RP] ... she states that for past several days patient has been sleepy and lethargic [drowsy or sleepy] and in recent few weeks, he has had significant weight loss. She states that she has had to repeatedly ask the staff at the nursing facility to order some labs and do work up to figure out why he was so sleepy ... ammonia [waste product processed by liver] noted to be 135 [normal range 10-47] lactulose [medication used to treat complications of liver (organ in the body)] ... and rectal [anus] tube ordered ...admit to telemetry [hospital unit] ..." During a concurrent interview and record review on 2/20/24 at 1:15 p.m. with the Director of Nursing (DON), the facility Policy and Procedure (P&P) titled "Weight Assessment and Intervention" dated 3/2022 was reviewed. The "P&P" indicated, "... resident weights are monitored for undesirable or unintended weight loss or gain ... undesired weight loss will be based on the following criteria ...1 month -5% weight loss is significant ... undesirable weight changes evaluated by the treatment team ... the physician and the multidisciplinary team identify conditions and medications that may be causing ... weight loss or increasing the risk of weight loss ... care planning for weight loss or impaired nutrition is a multidisciplinary effort and includes the physician, nursing staff, the dietitian, the consultant pharmacist, and the resident or resident's legal surrogate ... Interventions for undesirable weight loss are based on careful consideration ..." The DON stated there was no IDT meeting until 1/4/24 for Resident 1's weight loss. The DON stated the purpose of the IDT meeting was to identify trends and preventions for continuous weight loss taking risk factors into consideration. The DON stated the care plan should be implemented and followed by LNs. The DON stated the RD sends his recommendations to herself, managers, and the dietary supervisor. The DON stated recommendations from the RD should be communicated and implemented the day it was recommended. Durin