Health inspection·June 13, 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 Patient- §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 one of 14 final sampled patients (Patient 1) received the appropriate services needed to maintain acceptable parameters of nutritional status when: 1. The facility failed to implement the interventions to maintain Patient 1's nutritional status when Patient 1 experienced the following insidious weight loss (gradual, unintended, progressive weight loss over time): - 4 lbs, (3%) from 12/2/22 to 1/4/23, - 10 lbs (7%) from 10/3/22 to 1/4/23, and - 12 lbs (8%) from 8/5/22 to 1/4/22. 2. The facility failed to ensure the nutrition evaluations were performed by a qualified Registered Dietitian. 3. The facility failed to revise the patient-centered plan of care for Patient 1 to reflect the insidious weight loss from 8/5/22 to 1/4/23, and poor PO intake. These failures caused Patient 1 to experience severe weight loss of 11 pounds, 7.9% from 11/1/22 to 2/1/23; and severe weight loss of 16 pounds, 11% from 8/5/22 to 2/1/23. 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, "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 BSN (Balance Senior Nutrition) Solutions, titled, "Weight Loss in the Elderly: When Should You Be Concerned?" dated March 19, 2018, showed, "According to the Centers for Medicaid and Medicare services (CMS), weight can be a useful indicator of nutritional status when evaluated within the context of the individual's personal history and overall condition. Significant unintended changes in weight (loss or gain) or insidious weight loss may indicate a nutritional problem. "Insidious weight loss" refers to a gradual, unintended, progressive weight loss over time. https://www.bsnsolutions.net/weight-loss-in-the-elderly-when-should-you-be-concerned-clone#:~:text=%E2%80%9CInsidious%20weight%20loss%E2%80%9D%20refers%20to,progressive%20weight%20loss%20over%20time. 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 Assessment revised 10/2017 showed in part, 1. The dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each patient upon admission (within current baseline assessment timeframes) and as indicated by a change in condition that places the patient at risk for impaired nutrition. 2. As part of the comprehensive assessment, the nutritional assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the patient at risk for or with impaired nutrition. Review of the facility's P&P titled Weight Assessment and Intervention undated showed in part, the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our patients ...4. The Dietitian will respond within 24 hours of receipt of written notification. 5. The Dietitian will review the unit Weight Record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for "significant" weight change has been met. 6. The threshold for significant, unplanned and undesired weight loss will be based on the follow criteria [where percentage of body weight loss = (usual weight - actual weight) / (usual weight) x 100: a. one month - 5% weight loss is significant; greater than 5% is severe, b. three months - 7.5% weight loss is significant; great than 7.5% is severe, c. six months - 10% weight loss is significant; greater than 10% is severe ... Analysis 2. The Physician and multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk for weight loss ... Medical record review for Patient 1 was initiated on 5/2/23. Patient 1 was readmitted to the facility on 4/16/21, with diagnoses including Non-ST elevation myocardial infarction (NSTEMI), a type of heart attack and muscle weakness. Review of Patient 1's Annual History and Physical Examination dated 4/11/23, showed Patient 1 could make needs known but could not make medical decisions. Review of Patient 1's Physician's Order dated 12/1/22 to 1/31/22, showed the orders dated 4/16/21, for Regular No Added Salt diet and multivitamin one tablet PO QD for supplement. Review of the facility's document titled Vital Signs Grid from 4/16/21 through 5/3/23, showed the following weights and comparisons for Patient 1: * On 12/2/22 = 136 lbs, -7 lbs, a 4.9% insidious weight loss in three months [comparison weight on 9/1/22, 143 lbs], * On 1/4/23 = 132 lbs, -4 lbs, a 3% insidious weight loss in one month [comparison weight on 12/2/22, 136 lbs]; -10 lbs, a 7% insidious weight loss in three months [comparison weight on 10/3/22, 142 lbs]; and -11 lbs, a 7.7% insidious weight loss in six months [comparison weight on 7/5/22, 143 lbs]. * On 2/1/23 = 128 lbs, -4 lbs, a 3% insidious weight loss in one month [comparison weight on 1/4/23, 132 lbs]; -11 lbs, an 8% severe weight loss in three months [comparison weight on 11/1/22, 139 lbs]; -16 lbs, a 11% severe weight loss in six months [comparison weight on 8/5/22, 144 lbs]. Review of the facility's document titled Patient Care Details dated 11/1/22 to 4/30/23, showed Patient 1's PO intake for the following months: * For the month of November 2022, 48% of the 89 meals recorded, the intake was less than or equal to 50% intake. * For the month of December 2022, 38% of the 90 meals recorded, the intake was less than or equal to 50% intake. * For the month of January 2023, 35% of the 88 meals recorded, the intake was less than or equal to 50% intake. Review of the facility's document titled Nutrition Evaluation completed by the Certified Dietary Manager on 8/24/22, showed Patient 1's weight on 8/19/22 was 144 lbs. The patient had no weight gain or loss, was not at risk for weight loss and dehydration, and was on a Regular NAS (No Added Salt) diet. The document also showed no recommendations at this time, no concerns, and continue to monitor monthly weights. The Nutrition Evaluation form did not include Patient 1's PO intake. Review of the facility's document titled Nutrition Evaluation completed by the Certified Dietary Manager on 12/1/22, showed Patient 1's weight on 11/1/22, was 139 lbs. The patient had no weight gain or loss, was at risk for weight loss and dehydration, and was on a Regular NAS diet. The document showed N/A for nutrition interventions/recommendations and to continue to monitor monthly weight and po intake. The Nutrition Evaluation form did not include Patient 1's PO intake. Review of the facility's document titled Departmental Notes- Dietary completed by the RDN on 12/14/22, showed the RD notes were for a follow up on the patient's PO intake. The note showed the following: weight: 136 lbs, BMI (body mass index) 22.6, and normal status. Patient 1 had three lbs weight loss for one month, seven lbs weight loss for three months, and six lbs weight loss for six months. Patient 1 had been showing variable, low PO intake. Patient 1 had variable PO intake with an average of "20-40-50-70%" of all meals. Per the Certified Dietary Manager, Patient 1 refused to eat, notifying the nursing staff that she was not hungry. Dietary offered nutritional supplements, but the patient refused. The note showed a recommendation for appetite stimulant to improve PO intake; and would continue to monitor weights, labs, and PO intake. Review of the facility's document titled Nutritional Screening and Assessment - annual completed by the Certified Dietary Manager and RDN on 2/28/23, showed the current weight 128 lbs; IBWR (ideal body weight range) "121#--125#-138#;" recent weight change: loss of 4 lbs in one month, loss of 11 lbs (8%) in three months, and loss of 16 lbs (11%) in six months. The document showed estimated calories needs for weight maintenance based on actual body weight 25-30 calories/kg (kilogram) 1450-1740 calories; and recommendation for four-ounce HPN (High Protein Nourishment) BID (twice a day) at lunch and dinner. Review of the facility's document titled Nursing Summary completed by LVN 4 on 12/14/22 at 2240 hours, showed the patient's weight was 136 lbs on 12/2/22, with excellent appetite and no changes in condition. Review of the facility's document titled Departmental Notes- General Nurses Notes completed by RN 1 on 12/18/22 at 1028 hours, showed Patient 1 was on monitoring for poor PO intake, consumed 75% breakfast, and given fluid as tolerated. The note showed "snacks offered in between meals ...will continue to monitor." Review of the facility's document titled Departmental Notes- General Nurses Notes completed by LVN 4 on 12/18/22 at 0807 hours, showed Patient 1 had an episode of poor PO intake during dinner, consumed 30% of dinner. The note showed "alternate offered and refused ...will continue to monitor." Review of the facility's document titled Departmental Notes- General Nurses Notes completed by LVN 6 on 12/18/22 at 0724 hours, showed for Patient 1 to continue monitoring for low appetite. Review of the facility's document titled Departmental Notes- General Nurses Notes completed by LVN 5 on 12/19/22 at 1230 hours, showed in part, decreased appetite, ate 20% of breakfast and 30% of lunch, and when encouraged to eat, the patient became agitated and began to ramble and say things not pertaining to meal. When redirected, the patient stated, "I don't want to eat" or "I can't eat" or "I don't like this food." When asked what meal she preferred or what other food she would like to eat, the patient said nothing or yelled to leave her alone. Provided food that the family said she liked, but the patient also refused the meals. The note showed encouraged supplements and fluids as the patient could tolerate. Review of the facility's document titled Departmental Notes- General Nurses Notes completed by LVN 4 on 12/19/22 at 2257 hours, showed no episode of poor PO intake during dinner and consumed 100% of dinner. Review of the facility's document titled Departmental Notes- General Nurses Notes completed by the DSD/IP on 12/20/22 at 1103 hours, showed in part, the physician ordered CBC (complete blood count), CMP (complete metabolic panel), UA (urinalysis)/c+s (culture plus sensitivity). Review of the facility's document titled Departmental Notes- General Nurses Notes completed by LVN 4 on 12/20/22 at 1939 hours, showed the patient consumed 50% of dinner, alternate was offered and refused, and fluids were encouraged and offered as tolerated. Review of the facility's document titled Departmental Notes- General Nurses Notes completed by the DON on 2/3/23 at 2217 hours, showed Patient 1's weight was reviewed and the patient 's weight loss for six months. Patient 1 had a declining appetite. Physician 1 was made aware of the IDT recommendations for weekly weights, RD consult, fortify diet, and four-ounce HPN BID between meals; and agreed. Review of the facility's document titled Weight Variance Committee for Patient 1 dated 2/3/23, showed the following IDT members were present: the Certified Dietary Manager, DON, and SSD. The RDN was not present. The note showed the patient's average meal intake for breakfast, lunch, and dinner was 25-50%. The current weight was 128 lbs and BMI <22, and the identified weight trend was documented as -16 lbs x 6 months, with the known or suspected cause of decreased appetite. The current interventions was documented as none, and the physician and responsible party were notified on 2/3/23. Review of Patient 1's Physician Progress Notes dated 10/7/22, showed Patient 1's weight was 143 lbs, and to continue with the current orders. Review of Patient 1's Physician Progress Note dated 11/7/22, showed Patient 1 was doing fair and ate ok, and to continue with the current treatment. Review of Patient 1's Physician Progress Note dated 12/9/22, showed Patient 1 was alert, and to continue with the current medications. Review of Patient 1's Physician Progress Note dated 1/20/23, showed Patient 1 was awake but confused on and off, and to continue with the present plan. Review of Patient 1's Physician Progress Note dated 2/5/23, showed Patient 1 was doing fair, except more forgetful. The document showed oral intake fair, weight 128 lbs, and to continue with the current treatment. During the lunch meal dining observation on 5/02/23 at 1208 hours, Patient 1 was observed sitting in the patient dining room with two other patients at the table. Patient 1 appeared thin, confused, and was not eating her lunch. Patient 1 was asked why she was not eating, she replied, "I have too much at home." The DSD then asked Patient 1 if she wanted something else to eat but Patient 1 refused a meal alternative. Patient 1 consumed four ounces of juice and four ounces of HPN. On 5/2/23 at 1513 hours, Patient 1 was observed in the hallway sitting in her wheelchair drinking four ounces of HPN. On 5/02/23 at 1400 hours, an interview was conducted with the RDN. The RDN was asked to explain the patient weight loss protocol for the facility. The RDN stated significant weight loss of 5% in a month, 7.5% in three months, and 10% in six months were reviewed. The RDN talked to the DON but was not part of the IDT weight variance meeting. The RDN stated she was not involved in creating or revising the patient's care plans. On 5/3/23 at 1539 hours, an electronic medical review of Patient 1 and concurrent interview was conducted with the DON. The DON was asked to explain the patient's weight loss protocol for the facility. The DON explained the patients with significant weight loss of 5% in a month, 7.5% in three months, and 10% weight loss in six months were followed in the IDT weight variance committee. The nurses were responsible to notify t