Health inspection·August 11, 2023

o Facility: Eden Valley Care Center o Event ID: 9L1311 o Intake Number: CA00834005 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; _____________________________________________________________________ On 4/11/23, at 10:30 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding quality of care and treatment. The facility failed to ensure the interdisciplinary team (IDT, a group of health care professionals from diverse fields who work toward a common goal for residents) monitored the residents' weights, identified the residents who had unplanned weight loss, assessed and discussed the cause of unplanned weight loss, developed a care plan with a measurable goal and interventions, and provided necessary and timely interventions to maintain acceptable weights for Resident 1. In 12/2022, Resident 1 had a 7.6 pounds (lbs) weight loss (4.9% in 30 days) and the IDT recommended weekly weights to monitor. Resident 1's weekly weight was not monitored as the IDT recommended and there was no documented evidence the IDT had followed up the resident's weight loss. In 2/2023, the resident had a significant weight loss, 16.2 lbs in 90 days, at 137.8 lbs, the registered dietitian (RD) recommended weekly weights, but the weekly weight was not repeatedly monitored. Resident 1's attending physician had inaccurate monthly weights of Resident 1 and when the RD identified Resident 1's significant weight loss, there was no evidence the IDT discussed and assessed the cause of Resident 1's significant weight loss and care planned regarding the resident's weight loss. The care plan regarding the resident's weight loss was not updated and developed with a measurable goal and actual interventions to prevent further weight loss or specify the acceptable weight range. These failures resulted in Resident 1's significant weight loss and continuous weight loss in 5/2023. Findings: Review of Resident 1's face sheet indicated the resident was admitted to the facility on 8/30/21, with diagnoses including Alzheimer's disease (a progressive disease that destroys memory and mental functions) and Type 2 diabetes (a condition which affects the way the body processes blood sugar). Resident 1's admission weight was 151.6 pounds (lbs). Review of Resident 1's Food and Nutrition Services Assessment, dated 8/24/22 indicated Resident 1's weight was 156 lbs, her usual weight was "150's", and the desired/goal body weight was "stable weight." Review of Resident 1's Weight Change Note, dated 12/2/22 indicated, "IDT met for monthly weight meeting ... IDT recommends to cont. [continue] weekly weight, monitoring PO [by mouth] intake and follow up as needed." Review of Resident 1's short term: IDT monthly meeting care plan, dated 12/3/22 indicated current weight of 146.4 lbs. and weight loss of 7.6 lbs/4.9% in 30 days. A care plan intervention indicated, "Weekly weights," date initiated 12/3/22. Review of Resident 1's clinical record indicated there was no documented evidence Resident 1's weights were taken weekly after 12/3/22. Review of Resident 1's Food and Nutrition Services Quarterly Assessment (Registered Dietitian [RD] Assessment), dated 2/27/23, indicated Resident 1's current weight was 137.8 lbs and the rate of unplanned weight loss was greater than 5 percent (%) in 1 month, greater than 7.5% in 3 months, and greater than 10% in 6 months. The assessment indicated, "Unintended Weight Loss related to Psychological causes 2/2 [secondary to] depression as evidenced by weight loss of -16.2# [lbs] over last 90 days and -18.2# [lbs] over the last 180 days (significant weight loss)." It also indicated, "Please re-weigh, weigh weekly for 4 weeks. Will monitor nutrition intake and tolerance, and weight." Review of Resident 1's clinical record indicated there was no documented evidence Resident 1's weight was re-weighed. There was no documented evidence Resident 1's weights were taken weekly after 2/27/23. Review of Resident 1's potential nutritional problem care plan, dated 8/30/21, indicated, "2/27/23: 30 days: no data, 90 days: -16.2# [lbs] (-11.8%), 180 days: -18.2# (-13.2%). Significant weight changes..." The nutritional problem care plan was revised on 2/27/23. The care plan's goal, also indicated, "The resident will maintain adequate nutritional status as evidenced by maintaining weight within, no s/sx [signs and symptoms] of malnutrition, and consuming at least 50% of meals daily through review date. The care plan's "Goal" did not specify the range Resident 1's weight should be maintained within. There was no update or revision to the care plan's goal. The latest revision to the goal was 9/20/22. There was no update or revision to the care plan's "Interventions." The latest care plan intervention was initiated on 12/3/22. Review of Resident 1's clinical record indicated there was no documentation that indicated the IDT discussed the RD's recommendation and Resident 1's significant weight loss identified in the 2/27/23 RD assessment. There was no documentation that indicated the IDT followed up on Resident 1's continued weight loss, addressed Resident 1's depression, identified the possible cause of Resident 1's weight loss, or discussed interventions or plan regarding Resident 1's weight. Review of Resident 1's Weights and Vitals Summary, dated 5/11/23, indicated the resident's most recent weights were 146.8 lbs on 12/8/22, 143.6 lbs on 12/29/22, and 137.8 lbs on 2/2/23. Review of Resident 1's Physician's Progress Note, dated 12/27/22 indicated, "Wt [weight] 146.8 lbs- stable." Review of Resident 1's Physician's Progress Note, dated 1/30/23 indicated, "Wt 143.6 lbs- stable." Review of Resident 1's Physician's Progress Note, dated 2/13/23 indicated, "Wt 137.8 lbs- stable." Review of Resident 1's Physician's Progress Note, dated 3/20/23 indicated, "Wt 137.8 lbs- stable.", which was the resident's weight on 2/2/23. Review of Resident 1's Physician's Progress Note, dated 4/17/23 indicated, "Wt 137.8 lbs- stable.", which was the resident's weight on 2/2/23. During an interview on 4/11/23 at 2:04 p.m., the registered dietitian eligible (RDE) stated if he had a recommendation to add a resident to be weighed weekly, he would inform the administrator, charge nurse, and director of nursing. The RDE stated nursing staff is responsible for weekly weights and documenting the weekly weights. During an interview on 5/11/23 at 1:08 p.m., the MDS coordinator (MDSC) confirmed there was no weight input in Resident 1's electronic medical record after 2/2/23. The MDSC stated weights are documented on paper and then the previous director of nursing would enter the weights into the electronic medical record. During concurrent interview and record review, on 5/11/23 at 1:30 p.m., the MDSC stated Resident 1's weights were taken monthly and provided paper documentation of Resident 1's weights. The documentation indicated Resident 1's weight was decreasing at 137.6 lbs in March 2023, 133.8 lbs in April 2023, and 133.2 in May 2023. The MDSC confirmed there was no documentation Resident 1's weights were taken weekly after the RD's 2/27/23 assessment. During an interview on 5/23/23 at 11:45 a.m., the MDSC confirmed there were no new interventions added to Resident 1's potential nutritional problem care plan after 12/3/22. The MDSC stated any intervention could have been added at any time to address Resident 1's weight loss. During an interview on 5/23/23 at 11 a.m., the director of nursing (DON) stated there was no IDT meeting that addressed resident weights since March 2023. During an interview on 5/23/23 at 11:43 a.m., the DON stated in the past, IDT weight meetings were held by the dietary supervisor and involved all department heads, including the dietitian, DON, assistant DON, MDSC, and restorative nursing assistant. The DON stated she did not know how often IDT weight meetings were held. During an interview on 5/23/23 at 11:45 a.m., the MDSC stated there was no IDT meeting that addressed resident weights since March 2023. During an interview on 5/23/23 at 1:08 p.m., the dietary supervisor (DS) stated there was no IDT meeting that addressed resident weights since March 2023. During a telephone interview on 5/23/23 at 12:42 p.m., Resident 1's physician (MD) stated she was aware Resident 1 had gradual weight loss in February 2023 but was not sure Resident 1 was continuing to lose weight. During an interview with the registered dietitian (RD) on 5/25/23 at 12:50 p.m., the RD stated he would expect Resident 1 weekly weights to be done if it was a care plan intervention or an RD recommendation. The RD stated adding a resident on a list to be weighed weekly does not require an MD order. He stated it is within an RD's scope to add a resident to weekly weights. The RD stated that it falls under nursing to make sure the weights are being taken. He stated an RD not having the most updated weight would affect an RD's assessment. The RD also stated that it was important to work with the IDT. He stated there should have been documentation of an IDT discussion regarding Resident 1's weight. The RD confirmed Resident 1's care plan did not specify what Resident 1's weight should be maintained within. He stated the care plan should have a specific goal that is measurable, typically a target body mass index (BMI, a measure of body fat based on height and weight) range or a target weight range. The RD stated in the 2/27/23 RD assessment, after Resident 1's weight loss, there was no specific calculations for calorie, protein, or fluid needs and there was no target weight range indicated. During an interview on 6/6/23 at 1:18 p.m., the administrator (ADM) confirmed Resident 1 did not have weekly weights taken because there was no physician's order for weekly weights. During an interview and concurrent record review on 6/6/23 at 4 p.m., the ADM confirmed there was no documentation that the IDT discussed Resident 1's weight loss after 12/2/22. The ADM confirmed the last IDT note was on 12/2/22 and the note indicated the IDT would follow up as needed. The ADM stated if the RD were to review information and identify issues, then the IDT should follow up at that time. The ADM stated there were no nursing notes or IDT documentation regarding Resident 1's weight loss identified in the 2/27/23 RD assessment. The ADM also stated there was no documentation by the IDT regarding Resident 1's depression. The ADM confirmed there should have been some type of discussion and documentation by the IDT regarding Resident 1's weight loss after the 2/27/23 RD assessment identified significant weight loss. Review of the facility's policy, "Weight Assessment and Intervention," revised 3/2022 indicated the following: - Residents are weighed upon admission and at intervals established by the interdisciplinary team ... - The threshold for significant unplanned and undesired weight loss will be based on the following criteria [where percentage of body weight loss = (usual weight - actual weight)/(usual weight) x 100]: a. 1 month - 5% weight loss is significant; greater than 5% is severe b. 3 month - 7.5% weight loss is significant; greater than 7.5% is severe c. 6 month - 10% weight loss is significant; greater than 10% is severe - Undesirable weight change is evaluated by the treatment team whether or not the criteria for "significant" weight chance has been met. The evaluation includes the resident's calorie, protein, and other nutrient needs compared with the resident's current intake. - The physician and the multidisciplinary team identify conditions and medications that may be causing weight loss. - Individualized care plans shall address the identified causes of weight loss, goals and benchmarks for improvement and time frames and parameters for monitoring and reassessment. Review of the facility's policy, "Care Plans, Comprehensive Person-Centered," revised 3/2022, indicated the comprehensive, person-centered care plan includes measurable objectives and timeframes and the interdisciplinary team reviews and updates the care plan when the desired outcome is not met. Review of the facility's policy, "Care Planning - Interdisciplinary Team," revised 3/2022, indicated the interdisciplinary team is responsible for the development of resident care plans and the IDT includes but is not limited to the resident's attending physician, a registered nurse with responsibility for the resident, a nursing assistant with responsibility for the resident, a member of the food and nutrition services staff, the resident and/or the resident's representative and other staff as appropriate or necessary to meet the needs of the resident. In violation of the above cited standards, the facility failed to ensure the interdisciplinary team (IDT, a group of health care professionals from diverse fields who work toward a common goal for residents) monitored the residents' weights, identified the residents who had unplanned weight loss, assessed and discussed the cause of unplanned weight loss, developed a care plan with a measurable goal and interventions, and provided necessary and timely interventions to maintain acceptable weights for Resident 1. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of residents.