Other·March 9, 2023

§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 ensure Resident A maintained acceptable parameters of nutritional status when: 1. The facility failed to implement interventions to maintain Resident A's nutritional status when Resident A experienced the following weight loss: - a significant unplanned monthly weight loss of 9.2 lbs (5.3%) from 8/15/22 to 9/15/22 - a significant unplanned monthly weight loss of 8.8 lbs (5.4%) from 11/3/22 to 12/8/22 - a severe unplanned three-month weight loss of 13.1 lbs (7.8%) from 9/8/22 to 12/8/22 - a severe unplanned six-month weight loss of 19.5 lbs (11%) from readmission weight on 8/15/22 to 12/8/22 2. The facility failed to provide documentation showing the physician was notified of Resident A's unplanned significant monthly weight loss of 9.2 lbs (5.3%) from 8/15/22 to 9/15/22. 3. The facility failed to provide documentation Resident A's RP was notified of the following changes in condition for Resident A: - significant unplanned monthly weight loss of 9.2 lbs (5.3%) from 8/15/22 to 9/15/22 - significant unplanned monthly weight loss of 8.8 lbs (5.4%) from 11/3/22 to 12/8/22 - severe unplanned three-month weight loss of 13.1 lbs (7.8%) from 9/8/22 to 12/8/22 - severe unplanned six-month weight loss of 19.5 lbs (11%) from readmission weight on 8/15/22 to 12/8/22 4. The facility failed to revise the resident centered plan of care for Resident A for the following changes in condition: - significant unplanned monthly weight loss of 9.2 lbs (5.3%) from 8/15/22 to 9/15/22 - significant unplanned monthly weight loss of 8.8 lbs (5.4%) from 11/3/22 to 12/8/22 - severe unplanned three-month weight loss of 13.1 lbs (7.8%) from 9/8/22 to 12/8/22 - severe unplanned six-month weight loss of 19.5 lbs (11%) from readmission weight on 8/15/22 to 12/8/22 Findings: A professional reference review of American Academy of Family Physicians Journal titled, "Unintentional Weight Loss in Older Adults," dated 2014 showed, "Unintentional weight loss (i.e., more than a 5% reduction in body weight within six to 12 months) occurs in 15% to 20% of older adults and is associated with increased morbidity and mortality. In this population, unintentional weight loss can lead to functional decline in activities of daily living, increased in-hospital morbidity, increased risk of hip fracture in women, and increased overall mortality. Further, cachexia (loss of muscle mass with or without loss of fat) has been associated with negative effects such as increased infections, pressure ulcers, and failure to respond to medical treatments ..." https://www.aafp.org/afp/2014/0501/p718.html - afp20140501p718-b1. A professional reference review of the National Library of Medicine titled "Pressure Ulcer and Nutrition" dated 2018 showed, "Unplanned weight loss is a major risk factor for malnutrition and pressure ulcer development. Suboptimal nutrition interferes with the function of the immune system, collagen synthesis, and tensile strength." https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5930532/#: A professional reference review of Dietetics in Healthcare Communities, a dietetic practice group of the American Dietetic Association titled "Unintended Weight Loss in Older Adults: ADA Evidence Based Practice Guidelines" dated 2011 showed, "Most reference tables do not include elderly individuals in their subject pool, and thus these tables are not age adjusted. Standard height and weight tables and BMI tables are therefore not valid for use in older adults". https://higherlogicdownload.s3.amazonaws.com/THEACADEMY/4556f4af-bcea-4fd9-8fc9-5647e0d15658/UploadedImages/DHCC/Documents_/UWL.pdf 1. Review of the facility's P&P titled Nutrition (Impaired)/ Unplanned Weight Loss- Clinical Protocol revised 9/2017 showed in part, the section for "Assessment and Recognition" 2. The staff and Physician will define the individual's current nutritional status (weight, food/fluid intake, and pertinent laboratory values) and identify individuals with anorexia, weight loss or gain, and significant risk for impaired nutrition ...4. The staff will report to the Physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake. For the section titled "Treatment/Management" showed 2. The staff and Physician will identify pertinent interventions based on identified causes and overall resident condition, prognosis and wishes. For the section titled "Monitoring" showed 1. The Physician and staff will monitor nutritional status, an individual's response to interventions ... Medical record review for Resident A was initiated on 1/24/23. Resident A was readmitted to the facility on 8/14/22, with diagnoses which included Muscle Wasting and Atrophy (wasting or thinning of muscle tissue), Muscle Weakness, Peripheral Vascular Disease (circulatory condition which narrowed blood vessels reduce blood flow to the limbs), Dysphagia (difficulty swallowing), and Unspecified Dementia (progressive loss of intellectual functioning). Review of Resident A's Discharge MDS dated 8/7/22, showed under Section K, Resident A weighed 184 lbs and had not experienced a 5% weight loss or gain in the past month or 10% weight loss or gain in the past six months. Review of Resident A's History and Physical Examination dated 8/16/22, showed Resident A was readmitted from the hospital with urosepsis (infection in the blood caused by infections of the urinary tract), with intravenous (administered into a vein) antibiotics. The Physician noted Resident A was stable in the last month with no new event. Review of Resident A's Physician's Order dated 8/18/22, showed the following orders: - 8/18/22, a mechanical soft ground diet - 8/23/22, four ounces of cranberry juice TID (three times a day) - 8/30/22, four-ounce health shake with meals - 8/31/22, MVI (multi-vitamin) - 10/29/22, Zinc Sulfate (a mineral for wound healing) 220 mg daily - 30 cc prostat (protein supplement). Review of the facility document titled Resident Weight Tracking System Report from 8/14/22 through 1/25/23, showed the following weights and comparisons for Resident A: * On 8/15/22 = 173.8 lbs, -10.2 lbs, a 5.5% significant weight loss since previous admission [comparison weight on 8/7/22, 184 lbs], * On 9/15/22 = 164.6 lbs, -9.2 lbs, a 5.3% significant weight loss in one month [comparison weight on 8/15/22, 173.8 lbs], * On 12/8/22 = 154.3 lbs, -8.8 lbs, a 5.4% significant weight loss in one month [comparison weight on 11/3/22, 163.1 lbs]; -13.1 lbs, a 7.83% severe weight loss in three months [comparison weight on 9/8/22, 167.4 lbs]; and -19.5 lbs, an 11% severe weight loss since readmission [comparison weight on 8/15/22, 173.8 lbs]. Review of the facility document titled Dietary Assessment completed by the RD on 8/15/22, showed Resident A was 68 inches and weighed 173.8 lbs. Resident A was confused and had a poor appetite and intake, 25-50% on a regular texture diet. Resident A was noted with coughing and choking with meals. Resident A's skin was intact. The RD noted Resident A had weight loss of six lbs in the acute care hospital. The RD recommended to downgrade the diet to mechanical soft with ground meat, offer snacks, and encourage fluid between meals. Resident A was at risk for unintended weight loss and dehydration due to poor appetite and intake, infection, HTN (hypertension), dementia and needed assistance with meals. Resident A was at risk for pressure ulcer due to limited mobility. The RD documented for MDS triggers, Resident A was on IV treatment for infection and hydration. BMI was elevated, but the intake was poor, and no goal was identified for the resident's weight loss at this time. Review of Resident A's IDT notes written by the RD dated 8/23/22, showed no recent weight, new DTI on heel, and poor intake. The IDT recommended to add cranberry juice with meals for fluid, vitamin C, and calories. Review of Resident A's IDT notes written by the RD dated 8/30/22, showed current weight was not available, DTI on heel, and poor intake; and recommended to add health shake with meals, evaluate for MVI (multivitamin) supplement. Review of Resident A's IDT notes written by the RD dated 9/14/22, showed current weight was 167.4 lbs, weight loss of 6.4 lbs in three weeks. The resident's heel was debrided now unstageable. No new recommendations noted. Review of Resident A's IDT notes written by the RD dated 9/21/22, showed current weight was 164.6 lbs, weight loss of 2 lbs in a week. Intake was variable. No new recommendations were noted. Review of the facility document titled Dietary Assessment completed by the RD on 11/3/22, showed a significant change for Resident A. Resident A was on a mechanical soft ground diet, appetite was poor, and intake was 25-50%. Resident A was confused with swallowing difficulty and high risk for pressure ulcer. Resident A had a stage 4 pressure ulcer located on the right heel. Lab data dated 10/31/22, showed, "BUN (blood urea nitrogen) 11 ok." Current weight was 163 lbs, with weight loss of 19.6 lbs which was 10.7% in three months between admissions. Under the section titled Care Plan showed weight goal of 163 lbs +/- 3% per month x 90 days. Review of Resident A's MDS dated 11/4/22, showed under Section A0310, 4. Significant change in condition. The MDS showed a BIMS score of 12 indicating Resident A was mostly interviewable but with some confusion. Section K of the MDS indicated Resident A's weight was 163 lbs, and Resident A had experienced a 5% or more weight loss in the past month or 10% or more weight loss in the past six months and was not on a physician-prescribed weight-loss regimen. Review of Resident A's IDT notes written by the RD dated 11/8/22, showed current weight was 163.1 lbs, weight loss of 1.3 lbs in a month. The resident's right heel was open and debrided. The document showed a recommendation for magic cup (a fortified ice cream) at lunch. Review of Resident A's IDT notes written by the RD dated 12/6/22, showed current weight was 157.7 lbs, 3.4 lbs weight loss in a month; (elevated BMI) acceptable weight loss due to overweight. Resident A had a pressure ulcer to the right heel and poor intake. The document showed no interventions due to showing positive results from treatment. Review of Resident A's IDT notes written by the RD dated 12/13/22, showed current weight was 154.3 lbs, a 3.4 lbs weight loss in a week; (elevated BMI) acceptable weight loss due to overweight. Resident A had the right heel Stage 4 pressure ulcer and poor intake. The document showed no new interventions, continue current treatment, and to review next week. Review of Resident A's IDT notes written by the RD dated 12/27/22, showed the current weight was 152.6 lbs, a 2.9 lbs weight loss in a week. The document showed the resident's right heel Stage 4- nursing report improving, and heel protectors were helping. Intake was decreasing. The Social Service staff reported Resident A was not as alert as she used to be. The document showed need to encourage better intake, continue current treatment, and review next week. Review of Resident A's Physician Progress Notes from 8/16/22 to 10/27/22, showed Resident A was stable in the last month, no new event noted. The section where to record the resident's body weight was blank. Review of Resident A's Physician Progress Note dated 11/22/22, showed Resident A was stable in the last month, no new event noted. Resident A's weight was recorded as 161 lbs. There was no documentation of weight loss. Review of Resident A's Physician Progress Note dated 12/25/22, showed Resident A was stable in the last month. Resident A's weight was recorded as 153 lbs. The progress note further showed, "weight loss secondary to?" will start on Remeron (an antidepressant used to enhance appetite). On 1/24/23 at 0841 hours, an observation of the breakfast meal and concurrent interview was conducted with Resident A. Resident A stated she did not want to eat any of her breakfast meal and preferred only to drink the four-ounce health shake (a nutritional supplement). On 1/24/23 at 1300 hours, an observation of the lunch meal and concurrent interview was conducted with Resident A with CNA 1 present. Resident A was propped up in bed with CNA 1 assisting Resident A with her lunch meal. Resident A stated she did not like any of the food. CNA 1 stated Resident A did not eat solid foods and preferred liquids only, specifically health shakes. CNA 1 stated they encouraged Resident A to eat but she refused. On 1/25/23 at 0821 hours, an interview was conducted with the DON. The DON stated the protocol when a resident experienced a significant weight loss was to notify the physician and have a meeting with the IDT to discuss the resident's weight loss and implement interventions. On 1/26/23 at 1113 hours, an interview and concurrent medical record review of the initial skin assessment dated 8/14/22, for Resident A was conducted with RN 2. RN 2 stated the initial skin assessment showed Resident A's skin was intact with a skin tear to the right calf. The skin evaluation form dated 8/21/22, for Resident A was reviewed with RN 2. The skin evaluation form showed a DTI which measured 4.0 centimeters (cm) in length and 7.0 cm in width, UTD (undetermined) depth. Resident A's wound assessment form dated 10/27/22, completed by the Surgical and Wound Care Physician (SWCP) was reviewed with RN 2. The wound assessment form showed Resident A's right heel had a Stage 4 wound, measuring 4.0 cm in length, 6.0 cm in width and .4 cm in depth. The wound assessment form showed the right heel wound was "deteriorating" and positive for cellulitis (a common, potentially serious bacterial skin infection). The SWCP recommended Augmentin (an antibiotic) for 10 days. On 1/26/23 at 1159 hours, an interview was conducted with the DON. The DON confirmed weight loss was not indicated in a resident with a Stage 4 wound. On 1/26/23 at 1447 hours, an interview was conducted with CNA 1. CNA 1 was asked how she documented the percentage of the health shake taken for Resident A. CNA 1 stated the health shake was included in the total meal intake. If Resident A drank the health shake and magic cup but not other food, the intake was 25-50%. On 1/26/23 at 1500 hours, a medical record review for Resident A and concurrent interview was conducted with the RD. The Dietary Assessment completed by the RD, dated 8/15/22, and the discharge MDS dated 8/7/22 were reviewed. The RD confirmed she was responsible for Section K of the MDS. The RD stated she did not complete Section K of the discharge MDS dated 8/7/22, for Resident A. The RD acknowledged the weight for Resident A was 184 lbs on 8/7/22, as per the discharge MDS. The RD confirmed Resident A had lost "close to ten pounds" in the hospital and that the weight loss was significant. The RD stated she could not remember what weight she used to compare Resident A's admission weight of 173.8 lbs to, but that Resident A's usual body weight prior to discharge was 180 lbs. The RD confirmed Resident A was at risk for unintended weight loss, dehydration, and pressure ulcer development. The RD confirmed Resident A's skin was intact; intake was poor; the goal for Resident A was to keep weight stable at the admission weight of 173.8 lbs; and weight loss was not a goal. The RD confirmed she recommended to