Other·June 3, 2022

42 CFR §483.25 Nutrition/Hydration Status Maintenance 483.25 (g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostromy, and enteral fluids). Based on a resident's comprehensive assessment the facility must ensure that a resident: 432.25 (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 indicated otherwise. 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 12/16/21, at 2:45 PM, California Department of Public Health conducted an unannounced visit at the facility to investigate complaints regarding the quality of care for residents at the facility. Resident 1 was a 68-year-old female with diagnoses of hemiplegia (paralysis of one side of the body) following cerebral infarction (disrupted blood flow to the brain, a stroke) affecting left non-dominant side, dysphagia (difficulty in swallowing) following cerebral infarction, aphasia (difficulty communicating), and gastrostomy status (a tube in the stomach used for feeding) who was admitted to the facility on 8/30/21 Resident 7 was a 73-year-old female with diagnoses of hemiplegia (paralysis of one side of the body) following cerebral infarction affecting left non-dominant side, and abnormality of albumin (blood protein) who was admitted to the facility on 5/24/19. Based on interviews and record review, the facility failed to ensure the nutritional needs for two residents (Resident 1 and Resident 7) were met when the facility failed to: 1. Complete a Nutritional Assessment by a Registered Dietician (RD) and develop a care plan for weight loss for Resident 1. 2. Complete a Nutritional Assessment by a RD and follow the physician's order for Resident 7. These failures resulted in Resident 1 and Resident 7 experiencing unplanned weight losses of 8.46% and 7.5% respectively. Findings: 1. During a review of Resident 1's "Monthly Weight Report" (MWR), dated 1/11/22, the MWR indicated, "Aug [August] 260.0 Lbs [pounds]. . . Sep [September] 257.0 Lbs (3 lbs weight loss) . . . Oct [October] 253.0 Lbs (4 lbs weight loss) . . . Nov [November] 246.0 Lbs (7 lbs weight loss) . . . Dec [December] 246.0 lbs... Jan [January] 238.0 lbs." From August 2021 to January 2022, Resident 1 had an unplanned weight loss of 22 lbs (8.46%) within five months. During a review of Resident 1's "Minimum Data Set (MDS-clinical assessment tool)" dated 9/6/21, 9/12/21, 9/22/21, 12/7/21, and 12/29/21, the MDS indicated, Resident 1 was not on a planned weight loss regimen. During a concurrent interview and record review, on 12/16/21, at 3:47 PM, with Registered Nurse (RN), RN reviewed Resident 1's medical record. RN was unable to find a completed Nutritional Assessment by a RD. RN stated, Resident 1 received enteral feedings (feeding through a tube) since being admitted to the facility and a Nutritional Assessment was never completed. RN stated, there should have been a Nutritional Assessment completed by an RD within 72 hours of admission to ensure Resident 1 was receiving proper nutrition. RN stated, currently the facility did not have a RD. During a concurrent interview and record review on 12/16/21, at 4:45 PM, with Certified Dietary Manager (CDM), CDM reviewed Resident 1's medical record. CDM was unable to find a Nutritional Assessment in the resident's medical record. CDM confirmed the finding and stated a Nutritional Assessment should have been completed upon admit. During a concurrent interview and record review, on 1/5/22, at 1:27 PM, with Director of Nursing (DON), DON reviewed Resident 1's medical record. There was no nutritional care plan. DON confirmed no care plan was developed for Resident 1's weight loss and the resident should have had a nutrition care plan developed. During a review of the facility's policy and procedure (P&P) titled "Weight Assessment and Intervention" dated 9/08, the P&P indicated, "Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the physician, nursing staff, the Dietitian, the Consultant Pharmacist, and the resident or resident's legal surrogate. 2. Individualized care plans shall address, to the extent possible: a. The identified causes or weight loss; b. Goals and benchmarks for improvement; and c. Time frames and parameters for monitoring and reassessment." 2. During a review of Resident 7's "SBAR [Situation, Background, Assessment, Recommendation]-Change of Condition" dated 12/16/21, at 9:35 AM, the SBAR indicated, "Situation. . .difficulty with chewing regular food. Which started on 12/16/2021 in the morning. . .Response. . .Reported to primary care clinician. . .Recommendation's downgrade diet to mech [mechanical soft] ST Eval [Speech Therapy Evaluation] . . ." During a review of Resident 7's "Order Summary Report" (OSR), dated 12/31/21, the OSR indicated, "ST Eval and Tx [treatment] as indicated. . .order date. . .12/16/21. . ." During a review of Resident 7's "Weight and Vital Summary" (WVS) dated 1/6/22, the WVS indicated, "1/5/22. . .115 LBS.... Warnings. . .-7.5 % change [Comparison weight 10/1/21, 125 Lbs... .]." During a concurrent interview and record review on 1/5/22, at 3:22 PM, with Rehabilitation Coordinator (RC), Resident 7's "POC [Point of Care] Response History" (POCRH - electronic documentation completed by the Certified Nursing Assistants [CNAs] which includes meal percentage documentation) was reviewed. The POCRH from 12/28/21 to current indicated Resident 7 had a decrease in her meal intake. RC confirmed the findings and stated, she was aware Resident 7 had difficulty with chewing her food and the physician had downgraded Resident 7's diet and ordered a ST Eval and Tx. RC stated, the IDT [Interdisciplinary team- an approach to healthcare that integrates multiple disciplines through collaboration] had discussed Resident 7's ST Eval and Tx order and determined the ST Eval and Tx was no longer needed because staff were not reporting any further concerns with Resident 7 after the diet was changed. RC stated, she did not review Resident 7's meal intake documentation or the resident's weights. RC was unable to provide documentation the physician was notified of the IDT's decision to not carry out the physician's order for ST Eval and Tx. RC stated, the ST Eval and Tx should have been completed as ordered. During an interview on 1/5/22 at 3:34 PM, with Resident 7, Resident 7 stated, she was not eating very good and was having trouble with eating and swallowing. During an interview on 1/6/22 at 9:48 AM, with RN, RN stated, Resident 7 was having trouble chewing and the physician downgraded Resident 7's diet and ordered an ST Eval and Tx. During an interview on 1/6/22, at 10:07 AM, with CDM, CDM stated, when there was a significant change in a resident's weight the electronic medical record alerts staff. When a resident has a significant weight change the RD is notified and the RD completes a Nutritional Assessment and makes recommendations. CDM stated, the facility did not have a RD and Resident 7's weight loss was not assessed by a RD. No Nutritional Assessment was completed by the RD. During a review of the facility's P&P titled "Dietician [sic] Services" dated 2/17/16, the P&P indicated, "A qualified dietitian provides regularly scheduled visits to review services; annually at minimum and within 72 hours upon admission." During a review of the facility's P&P titled, "Weight Assessment and Intervention" dated 9/08, the P&P indicated, "Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing. Verbal notification must be confirmed in writing. 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 months - 7.5% weight loss is significant; greater than 7.5% is severe. c. 6 months - 10% weight loss is significant; greater than 10% is severe. . .Analysis. . .2. The Physician and the multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss. . .b. chewing or swallowing abnormalities. . .Interventions. . .chewing and swallowing abnormalities and the need for diet modifications. . ." In violation of the above cited standards, the facility failed to ensure Resident 1 and Resident 7's nutritional needs were assessed, and appropriate interventions were implemented, these failures resulted in Resident 1 and Resident 7's unplanned weight losses of 8.46% and 7.5% respectively. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and led to a Class A citation.