Health inspection·April 7, 2021

The following reflects the findings of the California Department of Public Health during the investigation of complaint # 699266 and 699960 abbreviated standard survey with Event ID N5FE11. Representing the Department, HFEN # 42167 State Citation A was written. F692 CFR 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- (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; (2) Is offered sufficient fluid intake to maintain proper hydration and health; (3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet. On 8/6/2020, at 10:55 AM, an unannounced visit was conducted at the facility to investigate the presence of a pressure injury. During the investigation, documents indicated Resident 1 had a weight loss of 30 pounds in 45 days. Resident 1 was a 77- year old female, admitted to the facility on 5/24/20. Her diagnoses included after care left hip surgery with difficulty in walking, dementia without behavioral disturbance (mental disorder that impairs memory and judgement), Depression (persistent sadness), and Paranoid schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly). Resident 1 required one-person assistance with eating. Due to social distancing, Resident 1 was not able to eat in the dining room related to Coronavirus Disease 2019 (COVID-19 - a highly contagious infectious disease caused by a new corona virus) prevention. Based on interview and record review, the facility failed to provide adequate nutrition for one of three sampled residents (Resident 1) when: 1. Certified Dietary Manager (CDM who is a member of the interdisciplinary team [IDT - a group of health care professionals such as Nurses, CDM, Registered Dietitian [RD], Therapists, Activity Personnel, Social Services who work together toward the goal of the resident) recommended weekly weights for Resident 1 and the weights were not completed. 2. The nursing staff did not notify the Primary Care Physician (PCP) and the Responsible Party (RP) of Resident 1's 20 pound (lbs. - unit of measurement) (-11.8 %) weight loss in one month. 3. The Fortified Diet (FD - a diet which contains foods that have extra added nutrients to aide in proper nutrition) recommended by the Registered Dietitian (RD) was not implemented. 4. The RD did not conduct a Nutrition assessment for the month of July 2020, when Resident 1's weight loss of 20 lbs. (-11.8 %) was initially noted. These failures resulted in Resident 1's unplanned total weight loss of 30 lbs (-17.65%) in 45 days. 1. During a review of Resident 1's "Admission Record" (AR), undated, the "AR" indicated the facility admitted Resident 1 on 5/24/2020 and transferred the resident to the hospital on 7/29/2020 related to altered mental status. Resident 1 returned to the facility on 8/15/2020 with a diagnosis of dysphagia (difficulty swallowing foods or liquids) and status post percutaneous endoscopic gastrostomy (PEG-a surgical procedure during which the doctor places a tube through the abdomen and into the stomach to deliver nutrition). During a review of Resident 1's "Weights and Vitals Summary (WVS)", the "WVS" documented weights were as follows: 5/26/2020: 170 pounds (lbs. - unit of measurement) 5/29/2020: 170 lb. 6/1/2020: 170 lbs. 7/1/2020: 150 lbs. (weight loss of 20 lbs. [-11.8 %] in one month) 7/8/2020: 143 lbs. (weight loss of 7 lbs. [-4.7 %] in one week) 7/15/2020: 140 lbs. (weight loss of 30 lbs. [-17.65 %] from 6/1/2020 to 7/15/2020). During a concurrent interview and record review on 8/5/2020, at 1:50 PM, with Director of Nursing (DON), Resident 1's "WVS" and "Progress Notes" (PN) under Interdisciplinary Team notes, dated 7/10/20 were reviewed. The WVS indicated, Resident 1 had a significant weight loss of 30 lbs. (-17.65%) from 6/1/20 to 7/15/20. Resident 1's PN, dated 7/10/20, indicated, "Recommendations: 2.) Weekly weight monitoring." DON confirmed the findings and stated, "[Resident 1] should have been weighed weekly." There was no documented weight on week 3 (6/9/2020) and no documented weight for week 4 (6/16/2020). During a concurrent interview and record review on 8/5/2020, at 1:50 PM, with DON, Resident 1's "Physician's Orders" (PO), dated 7/2/2020 was reviewed. The DON was unable to find documented evidence of weekly weights order as recommended by the CDM. DON stated, "They [the nurses] should have called the doctor to get an order." During a concurrent interview and record review on 10/20/2020, at 4:14 PM, with Minimum Data Set Coordinator (MDSC - a nurse that oversees and facilitate the completion of resident assessments and plans of care), Resident 1's care plan (CP) titled "Involuntary Weight Loss," dated 6/1/2020 to 7/15/2020 was reviewed. The MDSC was unable to find documented evidence weekly weights were included as an intervention in Resident 1's CP. MDSC stated, "We're all responsible for updating the care plan. The PCP should have been notified of the recommendation" and the care plan updated. During an interview on 10/20/2020, at 10:33 AM, with RD, RD stated, "Residents are weighed on admission and then weekly for about four weeks if the weight is stable." RD confirmed the following: 5/26/2020 to 7/29/2020: Week 1: 5/26/2020 - 170 lbs. (admission weight) Week 2: 6/2/2020 - 170 lbs. (taken 6/1/2020) Week 3: 6/9/2020 - No documented weight Week 4: 6/16/2020 - No documented weight RD stated the staff did not weight Resident 1 for two consecutive weeks (week 3 and week 4). During a review of the facility's policy and procedure (P&P) titled, "RD's For Healthcare, Inc. Weight Change Protocol", dated 2018, the P&P indicated, "Residents will be weighed on a monthly basis and weekly for those newly admitted and those deemed to be at high risk for weight changes." 2. During a concurrent interview and record review on 8/5/2020, at 1:50 PM, with DON, Resident 1's "PN" dated 7/1/2020 to 7/8/2020 were reviewed. The DON was unable to find documented evidence the nursing staff notified the PCP of the 20 lb. weight loss (6/1/2020 to 7/1/2020) of Resident 1. DON stated, "It looks like we did not communicate it with [PCP]." During a concurrent interview and record review on 8/5/2020, at 1:50 PM, with DON, Resident 1's "Meal Percentage Intake (MPI)," dated 7/9/2020 to 7/27/2020 was reviewed. The MPI indicated Resident 1 refused meals or snacks on the following days: 7/9/2020 Dinner 1X (refused dinner one time) 7/10/2020 Dinner 2X 7/12/2020 Dinner 1X 7/13/2020 Lunch 1X, Dinner 2X 7/14/2020 Lunch 1X, Dinner 2X 7/15/2020 Lunch 1X 7/17/2020 Breakfast 1X 7/18/2020 Breakfast 1X, Lunch 1X, Snack 1X 7/19/2020 Lunch 1X 7/20/2020 Dinner 1X 7/21/2020 Dinner 1X 7/22/2020 Dinner 1X 7/23/2020 Lunch 1X, Dinner 1X 7/24/2020 Refused all meals and snacks for 24 hours 7/25/2020 No documented meal or snack percentage 7/26/2020 Lunch 2X, Dinner 1X DON confirmed the findings and was unable to find documented evidence an alternate meal was offered to Resident 1. DON stated, "[Resident 1's] average meal intake is about 0-25% according to the [MPI]." During a concurrent interview and record review on 8/5/2020, at 1:55 PM, with Administrator, Resident 1's "PN" dated 7/1/2020 was reviewed. The Administrator was unable to find documented evidence the staff notified the RP of Resident 1's weight loss. The Administrator stated, "We should have notified family with the significant change of weight loss. I guess we missed it." During an interview on 8/6/2020, at 5:00 PM, with RP, RP stated, "The facility staff never called me or informed my mom (Resident 1) that she was losing that much weight. We talk to the nurses all the time and they never told us anything . . . If we knew then, we could have talked to her (Resident 1) about it." During a review of Resident 1's CP titled, "Chewing Difficulty," dated 6/4/2020, the CP indicated, "Notify physician and family/responsible party of weight change". During a review of the facility's P&P titled, "Notification of Change in Resident Health Status", undated, the P&P indicated, "The center will consult the resident's physician, nurse practitioner, or physician assistant, and if known notify the resident's legal representative or an interested family member when there is: A. Acute illness or a significant change in the resident's physical, mental, or psychosocial status. . . Notification: Depending on the nursing evaluation appropriate notification may be immediate to 48 hours." 3. During a review of Resident 1's "Nutrition Assessment" (NA), dated 6/15/2020, the "NA" indicated, "RD recommends: 1) MVM (multi-vitamin with minerals) PO QD (by mouth daily) as a supplement 2) Fortified foods (foods that have extra nutrients added to it to aide in proper nutrition)." During an interview and record review on 10/20/2020, at 4:10 PM, with CDM, Resident 1's physician's Orders (PO), dated 5/26/2020 was reviewed. The PO indicated Resident 1 was on a regular diet, pureed texture, regular (thin) consistency, fortified diet (FD - meals, snacks, and drinks to provide additional nutrients for higher nutrients). CDM stated, "I don't believe Resident 1 was on a fortified diet. She was initially on mechanical soft diet (foods that are soft and easy to chew) on admission, 5/24/2020 then it was changed to pureed (a diet that is soft, moist and smooth for people who have trouble chewing or swallowing) on 6/25/2020 by the [Speech Therapist] (ST) recommendation. . . We do not normally put them on a fortified diet. For weight loss, we try to give house supplements twice a day and weigh them weekly. . . I don't know why the diet is so inconsistent." CDM did not provide documented evidence the resident was still receiving a fortified diet. During an interview on 11/17/2020, at 8:07 AM, with RD, RD stated the ST can make recommendations about changing the texture of the diet, but does not make recommendations about fortifying a diet. RD stated unless the physician changes the order, the staff should have continued with the FD. 4. During a review of Resident 1's "WVS", the "WVS" documented weights were as follows: 5/26/2020: 170 lbs. 5/29/2020: 170 lbs. 6/1/2020: 170 lbs. 7/1/2020: 150 lbs. (weight loss of 20 lbs. [-11.8 %] in one month) 7/8/2020: 143 lbs. (weight loss of 7 lbs. [-4.7 %] in one week) 7/15/2020: 140 lbs. (weight loss of 30 lbs. [-17.65 %] from 6/1/2020 to 7/15/2020) During a concurrent interview and record review on 10/20/2020, at 10:33 AM, with RD, Resident 1's NA, dated 6/15/2020 was reviewed. There was no other documented evidence RD completed a nutrition assessment for Resident 1. RD stated, "I do my initial assessment within 14 days of admission. I come in every month for assessment or evaluation on residents with a 3% weight change in a week which is about a 5 lbs weight loss or weight gain, or if there is a trend and just based on clinical judgement." RD confirmed she did not complete a nutrition assessment for the month of July 2020, although the resident had lost a significant weight loss. During a review of the facility's P&P titled, "RD's For Healthcare, Inc. Weight Change Protocol", 2018, the P&P indicated, "Early identification of a weight problem and possible cause(s) can minimize complications. Assessment of residents experiencing weight changes should be completed in a timely manner. . . Evaluation: The Evaluation process is done again if there is a significant weight change." In violation of the above cited standards, the facility failed to implement weekly weights as recommended by CDM, report the weight loss of 20 lbs. or 11.8% in one month to the PCP and to the RP, implement the fortified diet recommended by RD, and conduct the nutrition assessment by RD for the month of July 2020, when Resident 1 was noted with a weight loss of 20 lbs. or 11.8 % in one month. These deficient practices presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and is the basis for the Class A citation.