Other·April 3, 2024

The following reflects the findings of the California Department of Public Health during the investigation of Complaint # 879084 Representing the Department: Health Facilities Evaluator Nurse 48263 State Citation AA was written: 42 CFR §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. 22 CCR § 72311. Nursing Service--General. (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited. (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. (D) A change in weight of five pounds or more within a 30-day period unless a different stipulation has been stated in writing by the patient's licensed healthcare practitioner acting within the scope of his or her professional licensure. 22 CCR § 72333. Dietetic Service - General. "Dietetic service" means a service organized, staffed and equipped to assure that food service to patients is safe, appetizing and provides for their nutritional needs. 22 CCR § 72339. Dietetic Service - Therapeutic Diets. Therapeutic diets shall be provided for each patient as prescribed and shall be planned, prepared and served with supervision and/or consultation from the dietitian. Persons responsible for therapeutic diets shall have sufficient knowledge of food values to make appropriate substitutions when necessary. 22 CCR § 72523. Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 1/24/24 at 10:31 A.M., the California Department of Public Health conducted an unannounced visit at the facility for the purpose of investigating a complaint of weight loss and no assistance with meals and hydration. Resident 1 was admitted to the facility with a history of malnutrition, hypertension, hyperlipidemia, and diabetes mellitus. Between 9/1/23 and 11/30/23 she lost approximately 23 pounds at the facility. The facility failed to: • Identify Resident 1's care needs based upon continuing assessment of her need for further interventions to assist with eating and fluid intake. • Develop and timely update the patient care plan to address Resident 1's poor appetite and low fluid intake, weight loss, aspiration risk, and chewing/swallowing problems. • Assure that dietetic services were provided to meet Resident 1's nutritional needs when the facility did not plan and implement recommendations/orders for daily nutrition and hydration. • Promptly notify attending licensed healthcare practitioners acting within the scope of their practice, including the physician and Speech Therapist, that Resident 1 had marked changes in her condition (poor appetite/meal refusal) and significant weight loss. • Implement weekly weight checks as prescribed by the physician, as recommended by the interdisciplinary team (IDT - team of individual with different specialties), and as stated in the care plan. • Follow its own policies and procedures for "Nutrition (impaired)/Unplanned Weight Loss-Clinical Protocol", "Hydration-Clinical Protocol", "Weight Assessment and Intervention", and "Care Plans Comprehensive-Centered". As a result, Resident 1 was found lethargic and hard to arouse. Resident 1 was sent to the hospital and diagnosed with acute kidney failure (a condition in which the kidneys suddenly cannot filter waste from the blood), metabolic acidosis (a condition when the body produces too much acid) and dehydration. Resident 1 died three days after admission to the hospital. Resident 1's causes of death were septic shock (a widespread infection causing organ failure and dangerously low blood pressure), acute kidney failure, and severe dehydration. A record review of Resident 1's undated Admission Record indicated Resident 1 was admitted to the facility on 7/1/23 with diagnoses that included a history of moderate protein-calorie malnutrition, dysphagia, hypertension, hyperlipidemia, and diabetes mellitus. Resident 1's historical record reviews did not include a diagnosis of any kidney issues. A record review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/5/23, indicated a Brief Interview for Mental Status (BIMS - used to measure a resident's mental status) score of 5 points out of 15 possible points which indicated Resident 1 had severe cognitive deficits. A record review of Resident 1's Nutritional Risk Assessment, completed by the Registered Dietitian (RD), dated 7/3/23, indicated that Resident 1 was no/low risk for alert, was able to feed herself, and had no chewing/swallowing problems. According to the assessment, Resident 1 should have her weight taken weekly. Resident 1's nutritional needs and hydration needs included the following: • 1890-2205 total calories (unit of energy) per day • 1575-1890 milliliters (ml) of liquids per day. A record review of Resident 1's care plan , dated 8/25/23, indicated that the resident had a nutritional problem due to inadequate nutrient intake related to decrease appetite. The care plan's interventions to address Resident 1's nutritional risks included monitor/document/report any signs of dysphagia, pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusal to eat, or appears concerned during meals. The care plan indicated to weigh the resident "weekly x4" (four times per week or monthly if her weight became stable) and monitor/record/report significant weight loss. One of the interventions included, "RD to evaluate and make diet change recommendations PRN (as needed)." An interview with certified nurse assistant (CNA) 1 was conducted on 2/1/24 at 12:56 P.M. CNA 1 stated that she had taken care of Resident 1 and was familiar with her care needs. CNA 1 stated that Resident 1 required encouragement to eat during meals. CNA 1 stated at times, she would sit with Resident 1 to physically assist her with her meals. CNA 1 stated, "If she [Resident 1] didn't eat, I would encourage her, and she would eat. I don't think the other CNAs did that with her, cause (because) they probably thought she would eat on her own." CNA 1 stated she notified the nurses when Resident 1 did not eat well. CNA 1 stated that CNAs documented the residents' meal intakes in the electronic medical record. CNA 1 stated that meal intakes were documented as, 0 for intakes of 0-25%; 1 for intakes of 26-50%; 2 for intakes of 51-75%; 3 for intakes of 76-100%. CNA 1 stated that if the resident ate 50% or less, an alternative meal or snack would be offered to the resident and documented on the meal intake electronic record. CNA 1 stated that an "NA" documentation would indicate that the alternate meal or snack was not offered, and a "RR" documentation would indicate that the resident refused the alternate meal or snack. CNA 1 also stated that a "0" documentation would indicate that the resident did not eat the alternate meal or snack. CNA 1 stated that Resident 1's fluid intake was documented in the electronic medical record. A record review of Resident 1's electronic meal intake documentation, from September 2023 to November 2023, was conducted. The dates listed below were dates when Resident 1 ate 50% or less : 9/6/23 - dinner: 1 (26-50%); NA - alternate or snack not offered 9/7/23 - lunch: 1; NA 9/11/23 - lunch: 1; NA 9/15/23 - breakfast: 0 (0-25%); NA 9/16/23 - lunch: 1; NA 9/19/23 - lunch: 1; NA 9/20/23 - lunch: 1; NA 9/23/23 - dinner: 1; NA 9/24/23 - lunch: 1; NA 9/26/23 - lunch: 1; NA 9/27/23 - lunch: 0; NA 9/30/23 - lunch: 1; NA 10/8/23 - lunch: 1; NA 10/8/23 - dinner: 0; 0 - did not eat alternate or snack 10/9/23 - dinner: 1; NA 10/11/23 - dinner: 1; NA 10/13/23 - lunch: 0; 0 10/13/23 - dinner: 0; 0 10/14/23 - lunch: 1; NA 10/15/23 - lunch: 1; NA 10/16/23 - dinner: 1; NA 11/1/23 - lunch: 1; NA 11/2/23 - breakfast: RR (resident refused); NA 11/2/23 - lunch: RR; RR 11/2/23 - dinner: RR; NA 11/3/23 - breakfast: RU (resident unavailable); 0 11/3/23 - lunch: NA; 0 11/4/23 - breakfast: 1; NA 11/4/23 - lunch: 0; NA 11/4/23 - dinner: RR; 0 11/5/23 - breakfast: 0; NA 11/5/23 - lunch: 1; NA 11/6/23 - lunch: 0; NA 11/6/23 - dinner: RR; 0 11/7/23 - breakfast: RR; RR 11/7/23 - lunch: 1; NA 11/7/23 - dinner: 1; NA 11/10/23 - breakfast: 0; NA 11/10/23 - lunch: no documentation 11/10/23 - dinner: no documentation 11/11/23 - breakfast: 0; NA 11/11/23 - lunch: RR; RR 11/11/23 - dinner: 0; NA 11/12/23 - dinner: 0; NA 11/13/23 - dinner: 1; NA 11/14/23 - breakfast: RR; RR 11/14/23 - lunch: 0; NA 11/15/23 - breakfast: RR; 0 11/15/23 - lunch: RR; RR 11/16/23 - breakfast: 1; NA 11/16/23 - dinner: 0; NA 11/17/23 - breakfast: RR; 0 11/18/23 - breakfast: 1; NA 11/18/23 - lunch: 1; NA 11/19/23 - breakfast: 0; NA 11/19/23 - dinner: no documentation 11/20/23 - dinner: 1; NA 11/21/23 - breakfast: 1; NA 11/21/23 - lunch: 1; NA 11/21/23 - dinner: RR; 0 11/22/23 - dinner: RR; 0 11/23/23 - dinner: RR; 0 11/24/23 - dinner: RR; 0 11/25/23 - dinner: RR; NA 11/26/23 - breakfast: RR; RR 11/26/23 - lunch: RR; RR 11/26/23 - dinner: no documentation 11/27/23 - breakfast: 0; NA 11/27/23 - lunch: RR; RR 11/27/23 - dinner: RR; 0 11/28/23 - breakfast: RR; NA 11/28/23 - lunch: RR; NA 11/28/23 - dinner: RR; 0 11/29/23 - breakfast: RR; RR 11/29/23 - lunch: RR; RR 11/29/23 - dinner: RR; 0 A record review of Resident 1's electronic fluid intake documentation, from September 2023 to November 2023, was conducted. The dates listed below were dates when Resident 1 did not meet the recommended daily fluid intake per RD's recommendation: 9/8/23: 720 ml/day 9/10/23: 720 ml/day 9/13/23: 840 ml/day 9/15/23: 880 ml/day 9/18/23: 800 ml/day 9/20/23: 680 ml/day 9/26/23: 880 ml/day 10/3/23: 720 ml/day 10/6/23: 480 ml/day 10/7/23: 640 ml/day 10/8/23: 920 ml/day 10/10/23: 480 ml/day 10/11/23: 820 ml/day 10/13/23: 940 ml/day 10/14/23: 860 ml/day 10/16/23: 880 ml/day 10/17/23 910 ml/day 10/18/23: 460 ml/day 10/19/23: 240 ml/day 10/20/23: 190 ml/day 10/23/23: 620 ml/day 10/24/23: 540 ml/day 1026/23: 720 ml/day 10/27/23: 760 ml/day 10/28/23: 720 ml/day 10/30/23: 480 ml/day 11/1/23: 840 ml/day 11/2/23: 240 ml/day 11/6/23: 600 ml/day 11/8/23: 630 ml/day 11/9/23: 380 ml/day 11/10/23: 240 ml/day 11/11/23: 360 ml/day 11/13/23: 360 ml/day 11/14/23: 680 ml/day 11/15/23: 840 ml/day 11/16/23: 930 ml/day 11/17/23: 240 ml/day 11/18/23: 720 ml/day 11/19/23: 730 ml/day 11/20/23: 840 ml/day 11/21/23: 600 ml/day 11/22/23: 860 ml/day 11/23/23: 600 ml/day 11/24/23: 880 ml/day 11/25/23: 590 ml/day 11/26/23: 120 ml/day 11/27/23: 498 ml/day 11/28/23: 520 ml/day 11/29/23: 280 ml/day A record review of Resident 1's weight from September 2023 to November 2023 was conducted. The record indicated the following weights: • 9/1/23: 139.6 lbs. (pounds) • 10/1/23: 133.6 lbs. - 6 lbs. weight loss in a month or 4.8% weight loss in a month • 11/1/23: 124.6 lbs. - 9 lbs. weight loss in a month or 6.7%. weight loss in a month A record review of the records from the Emergency Department (ED Note-Nursing dated 11/30/23 indicated that Resident 1 had a converted dosing weight (an adjusted body weight used to calculate the dose of drugs) of 116.845 pounds. A Record review of active physician's orders on 8/02/23 indicated Resident 1 was placed on a mechanical soft texture, thin liquids consistency, add fortified foods, small portions diet. The physician's orders on 11/02/2023 indicated weekly weight checks for four weeks on Saturday day shifts for four weeks and to document refusals. A Record review of Nutritional Risk Review (Quarterly) dated 9/1/23 indicated Resident 1 was at Moderate Risk for chewing/swallowing problems and High Risk for aspiration risk/precautions. A record review of Resident 1's Interdisciplinary (IDT) Note, dated 10/30/23 at 3:25 P.M. indicated, "weight loss of Wt (weight) hx (history) [sic]: (10/1) 133.6lbs; (9/1) 139.6 lbs; (7/1) 138lbs. Noted -6lbs/-4.3% clinically insignificant wt loss x1 mo (in/over the course of one month). Average PO (oral) intake mostly 51-100% per tasks... ...Recommend: continue diet as ordered, texture per SLP (speech-language pathologist; expert who works with individuals in the treatment of communication and swallowing problems), monitor weekly weights x4 (over the course of four) weeks, continue fortified (extra calorie) foods at meals..." A record review of Resident 1's SBAR (Situation, Background, Assessment, Recommendation) Summary for Providers, dated 11/2/23 at 12:53 P.M., indicated, "...Resident lost weight 9lbs [sic] in one month due to not eating and drinking enough..." A record review of Resident 1's weight loss care plan developed on 11/28/23 and revised on 11/30/23 indicated, "Weight Loss: Resident has an actual significant weight loss of 9 lbs. 6.7%, which was unintended weight loss x1 month; Goal: will show a desirable weight gain of 2-4 lbs in a month." The care plan indicated to encourage fluids and snacks and provide alternative meals of preference to promote increase in intake and food preference per the resident's choice. A record review of Resident 1's nurse's notes, dated 11/30/23 indicated Resident 1 was found lethargic and unresponsive at 9:30 P.M, was picked-up by ambulance at 10 P.M., and was taken to the hospital. A record review of Resident 1's hospital lab (laboratory) results indicated the following: 11/30/23 Sodium: 153 H (high) BUN (measures amount of nitrogen in the blood): 117 H (high) Creatinine (waste product produced by muscles and excreted by the kidneys): 6.3 H (high) Total Protein: 5.8 L (low) Albumin (a type of protein in the blood): 3.3. L (low) eGFR CKD-EPI (a measure that helps assess how well your kidneys are working): 6 L (low) Lactic Acid (provides insights into the body's metabolism): 3.3 L (low) Blood Gases (refers to the levels of oxygen and carbon dioxide in the blood for lung function) indicated Acidosis (may result from kidney issues. Occurs when there's too much acid in the body) 12/1/23 Lactic Acid: 9.8 C (critical) A record review of Resident 1's hospital emergency note, dated 11/30/23, indicated: Patient presents to the hospital with complaints of dyspnea (difficulty breathing), rapid respiratory rate. ...She initially had some hypotension (low blood pressure) which was improved with IV (intravenous - fluids administered through the vein) fluid. I was initially concerned for sepsis (a serious condition that happens when the body's immune system has an extreme response to an infection ) and treated the patient with broad-spectrum antibiotics along with 30 cc/kg (cubic centimeters/kilograms) IV fluid bolus (single dose) ... Reviewing her laboratory tests I see that