Health inspection·December 13, 2023

F692 §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- §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; §483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health; §483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet. The facility failed to implement a systematic approach to ensure effective monitoring of acceptable parameters of nutritional status for one of 19 final sampled residents (Resident 1) when: 1. The severe weight loss of - 10 lbs. (7.7%) from 7/20/23 to 9/25/23, and - 14 lbs. (10.4%) from 5/28/23 to 9/25/23, was not assessed and monitored by the IDT (Interdisciplinary team - members of the care team including but not limited to: the attending physician, nurses, a member of the food and nutrition services staff, social workers, rehabilitation therapists and the resident or the resident's legal representative). 2. The interventions ordered by Physician 1 to maintain Resident 1's nutritional and hydration status were not implemented as ordered. 3. The resident centered plan of care for Resident 1 did not reflect the goals or interventions in regard to dehydration risk. Findings: A professional reference review of the National Library of Medicine titled, "An approach to the management of unintentional weight loss in elderly people, "dated March 15, 2005, showed in part, "Unintentional weight loss, or the involuntary decline in total body weight over time, is common among elderly people who live at home. Weight loss in elderly people can have a deleterious effect on the ability to function and on quality of life and is associated with an increase in mortality over a 12-month period ...Unintentional weight loss is the involuntary decline in total body weight over time. In clinical practice, it is encountered in up to 8% of all adult outpatients and 27% of frail people 65 years and older. Weight loss is an important risk factor in elderly patients. It is associated with increased mortality, which can range from 9% to as high as 38% within 1 to 2.5 years after weight loss has occurred ...Weight loss of 4%-5% or more of body weight within 1 year, or 10% or more over 5-10 years or longer, is associated with increased mortality or morbidity or both. <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC552892/> A professional reference review of the Journal of Nutrients titled, "Chronic Dehydration in Nursing Home Residents," dated Nov 2020 showed in part, "The adult human body consists of about 60% water, with muscle functioning as the main reservoir of water, but in older adults, this amount is reduced to only around 50% due to reduced muscle mass. ... Among older adults, dehydration is common and is associated with several serious adverse events, including longer hospital stays and higher mortality (the state of being subject to death) rates ... Chronic dehydration mainly occurs due to insufficient fluid intake over a lengthy period of time, and nursing home residents are thought to be at high risk for chronic dehydration. ...Chronic dehydration is mainly due to insufficient fluid intake over a lengthy period and is often insidious (proceeding in a gradual way but with harmful effect) ... Older adults are considered at risk for chronic dehydration due to their reduced sensitivity to thirst, lower urine concentrating ability, and lower fluid intake compared with young or middle-aged adults. Furthermore, older nursing home residents may be at high risk for chronic dehydration because lower fluid intake is commonly observed in nursing home residents ...Chronic dehydration may be more problematic among nursing home residents, and establishing effective preventive strategies for chronic dehydration in this population would require identifying the risk factors for chronic dehydration." <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7709028/> A professional reference review of the National Library of Medicine titled, "Reducing urinary tract infections in care homes by improving hydration," dated July 10, 2019, showed in part, "Dehydration may increase the risk of urinary tract infections (UTIs), which can lead to confusion, falls, acute kidney injury and hospital admission ... Urinary tract infection (UTI) was the condition with the highest rate of emergency admissions to hospitals in 2012/2013. Dehydration has been highlighted as a common cause of admission to hospital in nursing home residents, and there is evidence that many older residents living in care homes do not receive enough fluids. <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6629391/> 1. Review of the facility's P&P titled Weight Assessment and Intervention revised 9/2008 showed in part, the multidisciplinary team will strive to prevent, monitor and intervene for undesirable weight loss for our residents. Analysis: 1. Assessment information shall be analyzed by the multidisciplinary team and conclusions shall be made regarding the: a. Resident's target weight range, b. appropriate calorie, protein and other nutrient needs compared with the resident's current intake; c. The relationship between current medical condition or clinical situation and recent fluctuations in weight ...2. Physician and the multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss. Care Planning 1. Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the Physician, nursing staff, the Dietitian, the Consultant Pharmacist, and the resident or resident ' s legal surrogate. 2. Individualized care plans shall address to the extent possible: a. The identified causes of weight loss; b. goals and benchmarks for improvement; and c. Time frames and parameters for monitoring and reassessment. Interventions: b. Nutrition and hydration needs of the resident; chewing or swallowing abnormalities and the need for diet modifications; the use of supplementation and/or feeding tubes ... Review of the facility P&P titled Acute Condition Changes revised 3/2018 showed in part, Monitoring and Follow-up 1. The staff will monitor and document the resident/patient's progress and responses to treatment, and the physician will adjust treatment accordingly. Medical record review for Resident 1 was initiated on 11/7/23 at 0920 hours. Resident 1 was readmitted to the facility on 10/31/23, with diagnoses which included metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), sepsis (a life-threatening complication of an infection), difficulty in walking, muscle weakness (generalized), and dysphagia (difficulty swallowing). Review of Resident 1's Annual History and Physical Examination dated 12/30/22, showed Resident 1 had fluctuating capacity to understand and make decisions. Review of Resident 1's quarterly Minimum Data Set (MDS, a resident assessment tool) dated 10/2/23, showed under Section C. Cognitive Patterns, a BIMS (brief interview for mental status) score of seven out of a possible 15, indicating Resident 1 had severe cognitive impairment. Section K of the MDS showed Resident 1's weight was 120 lbs and Resident 1 had experienced a weight loss of 5% or more in the last month or loss of 10% or more in the last six months and was not on a physician- prescribed weight-loss regimen. Review of Resident 1's Physician's Order dated 9/1/23 through 11/30/23, showed the following orders: - dated 9/26/23, for weekly weights for four weeks, every day shift, every Saturday until 10/22/23. - dated 10/31/23, for laboratory orders: CBC (complete blood count a measurement of white and red blood cells and platelets), CMP (complete metabolic panel, a blood test that provides information about body fluid balance, electrolytes - minerals in the blood and kidney function), Hgb A1C (a test that measures average blood sugar levels over the past three months), B12 (vitamin), D (vitamin), D25 (vitamin), liver panel, lipid panel (levels of fatty compounds in the blood) and Valproic acid (medication). - dated 11/3/23, to provide snacks three times a day. - dated 11/7/23, for a fortified (additional calories) pureed (smooth blended food) texture diet, regular liquid consistency. Review of the facility document titled Weights and Vitals Summary from 7/20/23 through 9/25/23, showed the following weights and comparisons for Resident 1: - On 9/25/23, weight = 120 lbs., -7lbs., 5.5% severe weight loss since 8/2/23 [comparison weight 127 lbs.], -10 lbs., a 7.7% severe weight loss in three months [comparison weight on 7/20/23, 130 lbs.], and -14 lbs., a 10.4% severe weight loss in six months [comparison weight on 5/28/23, 134 lbs.]. Review of Resident 1's meal intake records dated 9/25/23 - 10/23/23, showed 88% of the 68 meals recorded, the intake was less than or equal to 50%. Review of Resident 1's fluid intake records dated 9/25/23 - 10/23/23, showed for the 68 meals recorded, Resident 1's average meal fluid intake was 430 ml per meal or 1290 ml per day. Review of the facility document titled SBAR communication Form for Resident 1 signed and dated 9/25/23, by LVN 4 showed S. Situation: 1. The change in condition, symptoms, or signs I am calling in is/are weight loss of seven pounds (lbs.) from 127 lbs. (8/2/23) to 120 lbs. (9/25/23). The Physician was notified. R. Request 1a. Monitor vital signs, 1j. Other new orders: dietitian and psych consult. Review of the facility document titled Medicine Progress Notes signed and dated by Physician 1 on 9/27/23, showed in part, Resident 1 weighed 120 lbs. (-7 lbs.) and was noted with weight loss and variable appetite. Assessment: poor PO intake ...Plan: Continue with care plan, follow up with psychiatry and dietitian as needed, trend weights. Review of Resident 1's Nursing Services progress notes dated 9/25/23 - 9/28/23, showed on 9/25/23, LVN 4 documented per MD recommending diet and psych consult due to weight loss of seven lbs orders were in place and carried out; and sent a secure message to the social services and dietitian. Review of Resident 1's Post- COC/SBAR dated 9/28/23, showed LVN 5 documented Resident 1 was on monitoring for weight loss from 127 lbs to 120 lbs. Resident 1 refused dinner today and took medications as ordered with no signs or adverse effects. All needs had been met. Review of the facility document titled Weekly Summary for Resident 1 signed and dated on 9/28/23, by LVN 6 showed Section F. Nutrition/hydration as follows: - Section F4, Average intake: 60-75% - Section F6, Weight 120 lbs. - Section F7, Date when weight taken: 9/25/23, - Section F8, Previous weight 127 lbs. - Section F9, Date when weight taken: 8/2/23. - Section F10, Significant weight change: Weight loss. - Section F11, No labs drawn this week. - Section F16, Signs/symptoms of dehydration: None. Review of the facility document titled Weekly Summary for Resident 1 signed and dated on 10/2/23, by LVN 7 showed Section F4 - F16, no changes from the 9/28/23 weekly nursing summary. Review of the facility document titled Weekly Summary for Resident 1 signed and dated on 10/9/23, by LVN 8 showed Section F4- F16, no changes from 9/28/23, weekly nursing summary. Review of the facility document titled Weekly Summary for Resident 1 signed and dated on 10/18/23, by LVN 6 showed Section F4, average intake 70-85%; and Sections F6-F16, no changes from the 9/28/23 weekly nursing summary. Review of the facility document titled Weekly Summary for Resident 1 signed and dated on 11/1/23, by LVN 6 showed Section F4, average intake 70-90% and Sections F6-F16, no changes from the 9/28/23 weekly nursing summary. Nutrition/hydration: Review of the facility document titled Progress Notes signed and dated on 9/27/23, by the RD showed in part, Resident 1's monthly weight/consult: the resident with seven lbs, 5.5% weight loss in one month, 12 lbs., 9.09% weight loss in three months and 11 lbs., 8.4% weight loss in six months. Weight: 120 lbs. (9/25/23) ...Fortified diet, mechanical soft texture, regular liquid consistency with poor (less than 50%) PO (oral) intake. Patient is on snacks TID (three times a day), and supplement shakes TID ...No new labs noted. Estimated needs:..1375-1650 kcals (kilocalories), 25-30 kcal/kg ABW (actual body weight), 1375-1650 ml (milliliters, a unit of measure). Nutrition DX (diagnosis): inadequate oral food/beverage intake r/t poor intake AEB (as evidenced by) patient meeting 61% of estimated kcal and 64% of estimated protein needs with diet. Recommend to change to appetite stimulant per MD. Recommend to add ice cream BID (twice a day) with lunch and dinner for patient to try and SF (sugar free) prostat (protein supplement) 30cc (unit of measure) BID ...Will continue to follow weights, skin, labs and PO intake. Review of the facility document titled Nutritional Quarterly Review signed and dated by the DSS on 10/9/23, showed in part, Resident 1's diet order: fortified mechanical soft texture-regular liquid consistency, snacks TID between meals, ice cream with lunch and dinner. Appetite was poor, meal intake percentage 26-50%. Resident 1 had chewing problems. Most recent weight was 120 lbs on 9/25/23. Recent weight changes: RD note- monthly weight/consult patient with seven lbs., 5.5% weight loss in one month, 12 lbs., 9.09% weight loss in three months, and 11 lbs., 8.4% weight loss in six months. Review of Resident 1's hospital admission report dated 10/24/23, showed in part, Admitting diagnosis: Dehydration; Schizophrenia. Review of Resident 1's History and Physical examination from the acute care hospital dated 10/25/23, showed history of present illness: Resident 1 was noted to have progressively poor po intake. The resident was noted to be weaker and more confused than her usual baseline level. She was referred via regular ambulance to the acute care hospital emergency department where she underwent a preliminary workup. The results showed multiple abnormal values. She was subsequently admitted to the acure care hospital for further medical management. Review of Resident 1's physician hospital records dated 10/27/23 showed in part, Problem 1. Sepsis secondary to UTI (urinary tract infection). Assessment/plan 1. Continue with preadmission medications and diet. Gentle IVF (intravenous fluid) hydration, IV abx (antibiotics), Urine C&S (culture and sensitivity). Problem 2: Poor PO intake related to AFTT (adult failure to thrive; a syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function, and low cholesterol). Review of the facility document titled Nutritional Assessment - RD signed and dated by the RD on 11/2/23, showed in part, Resident 1's weight on 9/25/23, 120 lbs, usual body weight 120-135 lbs., goal weight 135 lbs. Weight loss > or = (greater than or equal to) 5% in 30 days: N/A not applicable. Weight loss > or = 10% in 180 days: no. Calorie needs: 1680-1960 kcals, Fluid needs: 1680-1960 ml. Meal intake percentage: 26-50%. Labs: none noted. RD notes/recommendations: Patient readmit. Patient with three lbs. 2.36% weight loss in three months and seven lbs. 5.34% weight loss in six months ...Patient on fortified diet, mechanical soft texture, regular liquid consistency with poor (25-50%) po intake ...Nutrition DX: inadequate oral food/beverage intake r/t variable po intake aeb patient meeting 55% estimated kcals and 80% of estimated protein needs with diet. Grandson okay with adding snacks b/w (between) meals TID (three times a day), ice cream BID (twice a day) with lunch and dinner and SF (sugar free) [prostat] (protein supplement) 30 cc BID to help meet needs ..