Health inspection·July 19, 2023

42 C.F.R. 483.25(g)(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. 22CCR 72315 (h) Each patient shall be provided with good nutrition and with necessary fluids for hydration. On 5/30/23, an unannounced visit was conducted at the facility for a recertification survey. The investigation found the facility failed to follow the policy and procedure (P&P) titled, "Weight Assessment and Intervention," to ensure the significant unplanned weight changes for Resident 73 had updated care plan interventions and that those interventions were carried out and monitored for their effectiveness to avoid further weight change. This failure resulted in significant, unplanned weight changes for Resident 73 and had the potential to result in malnutrition (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable to use the food that one does eat). Resident 73's medical record, undated, indicated, Resident 73 was admitted on 11/2/22 with diagnoses of schizophrenia (mental disorder that affects a person's ability to think, feel, and behave clearly) and anxiety (mental disorder that causes worry and fear about everyday situations). Resident 73 was prescribed a regular diet. Resident 73 had a 4-ounce health shake that was ordered on 4/6/23 to be given one time a day per resident request. Staff did not record intake for the health shakes. From 11/2023 to 5/2023, Resident 73 had a weight loss of 11.9%. (21 pounds), Weight loss of 10% of a resident's usual body weight in 6 months is considered severe. Resident 73's "Nutrition Assessment," dated 11/17/22, the "Nutrition Assessment" indicated, Resident 73 had "inadequate oral intake r/t [related to] loss of appetite AEB [as evidenced by] po [oral] intake 47-64%. . . Recommendation Provide (sic) cold cereal for breakfast Add (sic) 4 oz [ounce] health shake BID [two times a day] with breakfast and dinner." Resident 73's "Order Summary Report" (OSR), dated 4/6/23, the "OSR" indicated, Health Shake as needed per resident request, may have one time a day. Resident 73's "Weights and Vitals Summary (WVS), undated, the "WVS" indicated, Resident 73 was admitted on 11/2/22 with a weight of 179 pounds (lbs). Resident 73 was weighed monthly and had the following recorded weights: 11/8/22 176 lbs 11/29/22 175 lbs 12/09/22 175 lbs 1/6/23 171 lbs 2/3/23 167 lbs 3/3/23 163 lbs 4/3/23 159 lbs 5/3/23 155 lbs 11.9% (21 lbs) weight loss in 6 months. Resident 73's "Minimum Data Set" (MDS - a standardized assessment and care planning tool), dated 5/11/23, the "MDS" indicated, Resident 73 had a BIMS (Brief Interview for Mental Status) score of 15 which indicates cognitively (thought process) intact. The "MDS" indicated Resident 73 had a greater than 10% significant, unplanned weight loss in six months, and was not on a physician prescribed weight loss regimen. Resident 73's "Documentation Survey Report" (DSR), dated May 2023, the "DSR" indicated, Resident 73 refused breakfast 16 out of 31 days in the month of May. Resident 73's "Documentation Survey Report" (DSR), dated April 2023, the "DSR" indicated, Resident 73 refused breakfast 28 out of 30 days in the month of April. Resident 73's "Documentation Survey Report" (DSR), dated March 2023, the "DSR" indicated, Resident 73 refused breakfast 30 out of 31 days in the month of March. Resident 73's "Medication Administration Record" (MAR), dated April 2023, the "MAR" indicated, Resident 73 did not receive a health shake in April 2023 for 24 consecutive days. Resident 73's "Medication Administration Record" (MAR), dated May 2023, the "MAR" indicated, Resident 73 did not receive a health shake in May 2023 for 30 consecutive days. During a concurrent observation and interview on 6/1/23, at 12:10 p.m., with Resident 73, in the dining room, Resident 73 was sitting at the table eating. Resident's clothing appeared loose and did not fit well. Resident 73 did not finish his meal tray. Resident 73 stated, he did not like the food. Resident 73 was hard to hear when he spoke, did not make eye contact, and appeared timid. Resident 73 stated, he did not want anything else to eat. Resident 73 stated, he has never had the health shake. He did not like vanilla but likes chocolate or strawberry and would be willing to try it in those flavors. During an interview on 6/1/23, at 12:18 p.m., with Certified Nursing Assistant (CNA) 4, CNA 4 stated, Resident 73 refused breakfast today. Resident 73 did not get a health shake with meals according to resident diet list that CNA 4 had printed. During an interview on 6/1/23, at 12:23 p.m., Resident 73 stated, "I'm having trouble waking up in the morning." Resident 73 stated, he did not want to "bother" the staff and that is why he did not ask for the health shake. Resident 73 stated, he preferred cereal and would eat the cereal if he could have it later in the morning. During an interview on 6/1/23, at 4:10 p.m., with Registered Dietician (RD), RD stated, she saw that Resident 73's weight was trending down. RD stated, she talked to him, but he did not want to engage in his meals. RD stated, "I talked to staff, and they said that he didn't want to get out of bed." RD stated, "I don't think he will ask for the shake; it needs to be offered." Resident 73's weight was discussed with RD, and the RD stated, weight was trending down, he was losing weight. That is pretty significant." RD stated, his (Resident 73's) intake was not good, it would be beneficial to closely monitor his weight every week. RD stated, he would benefit from weekly weights so we can continue to intervene as necessary. RD stated, sometimes it could be challenging with this population. A lot of the medications can cause drowsiness or fatigue. She stated she did not discuss Resident 73 not wanting to get out of bed with the team in the recent weight variance meeting. RD stated, it was reasonable for the resident to request to have a later breakfast of cold cereal. RD stated, "I should have put in an updated care plan" for the cold cereal, later breakfast time and health shakes. RD stated, she did not think the health shake should have been changed from twice daily. RD stated, "Not sure if it was even started. I'm sure there is some discrepancy." During a concurrent interview and record review, on 6/2/23, at 8:36 a.m., with Minimum Data Set Nurse (MDSN) 1, Resident 73's medical record (MR), dated 11/2/22 6/2/23 was reviewed. Resident 73's care plan for nutrition, updated 5/12/23, indicated, the care plan was not updated to include the BID (twice a day) health shakes, cold cereal for breakfast, or weekly weights. The "Nutrition Assessment," dated 11/2/23 indicated, RD recommended health shake with breakfast and dinner. MDSN 1 stated, Resident 73 does not always have the capability to ask for the health shake. MDSN 1 could find no documentation that the RD recommendation made on 11/17/22 was carried out. MDSN 1 stated, without the documentation, there was no way to monitor if the intervention was effective. The Interdisciplinary (multiple disciplines working together) Team (IDT) should document root cause for the poor appetite. It was not documented. MDSN 1 stated facility did not follow the policy for monitoring and evaluating weight and did not individualize the care plan for Resident 73. During a concurrent interview and record review on 6/2/23, at 8:45 a.m., with MDSN 2, Resident 73's MR, dated 11/2/22 6/2/23 was reviewed. The OSR indicated, no physician order for the health shake to be given BID with breakfast and dinner was ever written. MDSN 2 stated, he could not find the order for the BID health shake or any documentation that Resident 73 ever received the health shake. The weight history from 11/2/22-5/31/23 for Resident 73 was reviewed with MDSN 2. The weight history indicated Resident 73 had weight loss that was trending down since admission. MDSN 2 stated, it would benefit Resident 73 to be on weekly weights to monitor his weight loss more closely. MDSN 2 stated, Resident 73 was sleepy, withdrawn, and it could be difficult to get him up in the morning. MDSN 2 stated medications could be a cause, and that it was hard to assess if he is sleepy or depressed. MDSN 2 stated, facility had not addressed possible depression or medication issues in the weight interdisciplinary team meeting. MDSN 2 stated, weight loss could be a nursing issue. MDSN 2 stated, facility did not follow the policy to evaluate the root cause for Resident 73's weight loss. A review of the facility's policy and procedure (P&P) titled, "Weight Assessment and Intervention," dated 1/12/18, the P&P indicated, "The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight change for our residents. . .The dietician will review monthly weights to follow individual weight trends. Negative trends will be evaluated by the treatment team whether or not the criteria for 'significant' weight change have been met. . .Individualized care plans shall address to the extent possible: a. The identified cause of weight change. . . Interventions for undesirable weight change shall be based on careful consideration of the following. . . a. Resident choices and preferences. . . d. Environmental factors that may inhibit appetite or desire to participate in meals." According to State Operation Manuel (SOM) Appendix PP, dated 2/2/23, indicated, "...Suggested parameter for evaluating significance of unplanned and undesired weight loss are...Interval... 6 months...significant loss 10%...Severe loss...greater than 10%..." In violation of the above cited standards, the facility failed to follow the policy and procedure (P&P) titled, "Weight Assessment and Intervention," to ensure with significant unplanned weight changes were carried out and monitored to avoid further weight changes for Resident 73. This failure resulted in significant, unplanned weight changes for Resident 73 and had the potential to result in malnutrition (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable to use the food that one does eat). This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.