Other·April 8, 2021

F656 §483.21(b) Comprehensive Care Plans Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. On 4/16/20, an unannounced visit was conducted at the facility to investigate two complaints regarding Resident 1's quality of life. Resident 1 is a 76-year-old male who was admitted to the facility on 2/28/20. He had multiple medical conditions including: Inclusion body myositis, heart failure, diabetes, and chronic pain, and other symptoms and signs concerning food and fluids intake. [Inclusion body myositis is caused when the body's immune system goes awry and attacks its own tissues - in this case, the muscles. The symptoms included weakness of the wrist and finger muscles, shrinking of the muscles of the forearms, weakness of the large muscles on the front part of the thighs, weakness of the lower leg muscles, and weakness of the esophageal (muscular tube connecting the throat with the stomach which can cause difficulty swallowing) muscles. Inclusion body myositis patients with swallowing difficulties can suffer from poor nutrition as well as choking on food or drinks.] Based on interview and record review, the facility failed to develop a comprehensive nutritional care plan in 14 days for Resident 1 to address his risks of having nutrition-related health consequences, such as loss of appetite, difficult swallowing, and inability to use hands/fingers to eat independently. This resulted in Resident 1 losing 10 pounds, 4.7%, of his usual body weight, from 3/13/20 to 3/21/20, within eight days. The Resident Assessment Instrument (RAI) Manual 3.0, 2019 (a manual released by the Centers for Medicare & Medicaid Services (CMS) offers clear guidance about how to use the RAI correctly and effectively to help provide appropriate care to residents.) A comprehensive care plan is a patient-centered plan to care for an individual patient's needs. It contains all of the relevant information about a patient's diagnoses, the goals of treatment, the observations needed, actions that must be performed, and a plan for evaluation. A comprehensive assessment is the first step in care planning. In long- tem1 care, the Minimum Data Set (MDS) is a preliminary assessment to identify potential resident problems, strengths, and preferences. Care Areas are triggered by MDS responses that indicate the need for additional assessment based on problem identification. The triggering of a care area indicates the facility needs to conduct more review to identify if additional assessment is needed. Then the staff reviews the information gathered through further review to determine whether the resident needs a new care plan or changes to an existing care plan. The decision to start a new care plan or revise an existing one is documented on the "Care Area Assessment Summary." The comprehensive care plan should be developed within seven days after completion of the MDS, 14 days after admission. Findings: During a review of Resident l 's MDS, dated 3/5/2020, indicated Resident 1 had a problem in maintaining nutritional balance related to his contractures, inability to sit up, poor memory, anxiety, heart issues, digestive tract illness, and diuretics use. There was a note, under "Analysis of Findings," read: "res (resident) is mechanically altered with a very good po (oral) intake at this time 75-100% continue to feed himself also have difficulty with swallowing as well." The comprehensive assessment triggered "Nutritional Status" as a concerned care area for Resident 1 and the interdisciplinary team decided to proceed with a care plan to address his risk for nutritional deficit. In the "Care Area Assessment Summary" of the same MDS, it indicated; "New Care Plan Started" for nutritional status. During a review of Resident 1'scare plans, there was no care plan found in his medical records to address his nutritional status and risk of developing nutrition related problems such as dehydration or weight loss. During a review of the Registered Dietician's (RD) "New Admission" note, dated 3/4/20, Resident 1's usual body weight was around 210 pounds. During a review of Resident 1's "Weight Data" log, dated 2/29/20 thru 4/6/20, the log indicated Resident 1 weight 211 pounds on admission, 2/29/20. On 3/13/20, he maintained his weight at 211 pounds. On 3/21/20, Resident 1 weight 201 pounds, a 10-pound loss. During a more in-depth review of Resident l 's Meal Percentage log, dated March 2020, indicated the resident, from 3/1/20 to 3/12/20, was able to take at least 25 percent of the meals served. From 3/13/20 to 3/31/20, the meal intakes are listed below: 3/13/20-only took 25% of dinner. No documentation for breakfast and lunch. 3/14/20-took 100% breakfast and 50% dinner. No documentation for lunch. 3/15/20-took 25% breakfast, 50% lunch, and 50% dinner. 3/16/20-took 25% breakfast, refused lunch, and took 100% dinner. 3/17/20-took 25% breakfast, 10% lunch, and no documentation for dinner. 3/18/20-took 50% breakfast, 25% lunch, and 100% dinner. 3/19/20-took 25% breakfast, no documentation for lunch, and 100% dinner. 3/20/20-did not eat breakfast, refused lunch, and no documentation for dinner. 3/21/20-no documentation for meals entire day. 3/22/20-no documentation for breakfast and lunch, refused dinner. 3/23/20-no documentation for breakfast, refused lunch and dinner. 3/24/20- no documentation for breakfast and lunch, refused dinner. 3/25/20 and 3/26/20-re fused breakfast and no documentation for lunch and dinner. 3/27/20-no documentation of any meal intake. 3/28/20-refused breakfast and dinner, no documentation for lunch. 3/29/20-took 10% breakfast, no documentation for lunch, refused dinner. 3/30/20-no documentation on meal intake. 3/31/20-refused breakfast, no documentation for lunch and dinner. During a review of March 2020 "ADL (Activities of Daily Living) FLOW SHEET ADDITIONAL NOTES," completed by a certified nursing assistant (CNA), it indicated on 3/12/20, at 1:35 PM, "nurse and therapy notified that resident hasn't been eating right complains of taste. Offer alternate or pudding." At 6:00 PM, another CNA documented: "R (Resident) ate 25% dinner alt (alternate) offered and ref (refused), c/n (charge nurse) notif (notified)." On 3/25/20, another CNA documented; "R (resident) refused breakfast, charge nurse notified." The ADL flow sheet from 4/1/20 to 4/12/20 was reviewed. Of the 36 meals served, Resident 1 ate 25% of breakfast on 4/2/20 and 25% lunch on 4/3/20, refused 25 meals, and facility staff did not document nine meal intakes. There were a few notes on the "ADL FLOW SHEET ADDITIONAL NOTES" section: On 4/8/20, at 7:30 AM, the note indicated; "[Resident 1] refusing to eat or drink. He keeps spitting out food and drinks, nurse notified." On the same day, at 12:30 PM, the note indicated; "[Resident 1] is refusing to eat lunch or drink he keeps spitting it out nurse notified." The third note was entered on 4/11/20, no time, indicated; "[Resident 1] refused dinner, tried feeding him, but he would yell continue to spit everything out." On 4/13/20, at 7:00 AM, a CNA documented: "CNA [Certified Nursing Assistant] fed resident he couldn't chew and started spitting food out C/N [Charge Nurse] aware." On the same documentation, five hours later, another CNA documented the facility transferred Resident 1 to an acute care hospital. The admitting physician at the hospital Emergency Department assessed Resident 1 as severely dehydrated (not enough water in the body), with hemoconcentration (concentrated blood or thickened blood usually resulting from loss of fluid to the tissues from blood vessels). During a concurrent interview and record review on 8/14/20, at 11:04 AM, with Minimum Data Set Coordinator Assistant (MDSCA), MDSCA reviewed Resident 1's meal percentage log for 3/20/20 thru 4/13/20. MDSCA confirmed the log had missing documentation and Resident 1 had refused meals. During a concurrent interview and record review, on 11/4/20, at 10:34 AM, with Dietary Supervisor (DS), DS reviewed Resident 1's Weight Data log. DS confirmed Resident 1 had weight 211 pounds on 3/13 and 201 pounds on 3/21, indicating Resident 1 had lost 10 pounds in eight days. DS stated Resident 1 had a weight loss, and the weight loss was not a planned weight loss. During a concurrent interview and record review, on 11/4/20, at 11:26 AM, with the Director of Nursing (DON) and Chief Nursing Officer (CNO), both the DON and CNO confirmed Resident 1's weight loss may be related to the poor meal intake and DON stated, "There should have been an intervention, and SBAR [situation, background, assessment, and recommendation; a communication from used to identify a residents change of condition before calling the physician] It just got missed." During a concurrent interview and record review on 11/19/20, at 11: 19 AM, with the DON, DON reviewed Resident l 's medical records and was unable to find any care plan developed by staff to address Resident l's nutritional risk factors or poor oral intake. DON stated, "He (Resident 1) doesn't have a nutritional care plan. (There was) No baseline either (comprehensive care plan). He should have had one. There should have been a baseline (care plan) on admission and an updated care plan when he [Resident 1] started to lose weight." During a review of the facility's policy and procedure (P&P) on Nutrition (Impaired)/Unplanned Weight Loss-Clinical Protocol," revised September 2012, subtitled "Monitoring" indicated: "1. The physician and staff will closely monitor residents who have been identified as having impaired nutrition or risk factors for developing impaired nutrition. Such monitoring may include: a. Evaluating the care plan to determine if the interventions are being implemented and whether they are effective in attaining the established nutritional and weight goals; (1) Evaluating the resident's response to interventions should be based on defined criteria for improvement/worsening of nutritional status; for example, stabilization of weight, laboratory values, or food/fluid intake." During a review of the facility's P&P titled, "Care Plans-Comprehensive," revised September 2010, it indicated, "7. The resident's comprehensive care plan is developed within seven (7) days of the completion of the resident's comprehensive assessment (MOS). 8. Assessment of residents are ongoing and care plans are revised as information about the resident's condition change." The facility staff did not develop a comprehensive nutritional care plan for Resident 1 in 21 days after his admission to intervene or minimize the risks for weight loss, nor did the facility initiate a care plan when the resident started to eat poorly. During a review of Resident l's hospital's medical records, the "Discharge Documentation," dated 4/17/20, indicated "Resident 1 expired at 8:43 AM." His discharge diagnoses included dehydration, sepsis (blood infection), acute kidney injury (A sudden, serious drop in blood flow to the kidneys related to sepsis, not enough fluid in the body), and hypoxemic respiratory failure (not having enough oxygen in blood). In violation of the Code of Federal Regulations §483.21(b), the facility failed to develop a person centered comprehensive nutritional care plan for Resident 1 to address his risks of having nutrition-related health consequences. This resulted in Resident 1 losing 10 pounds, 4.7%, of his usual body weight within eight days. This violation presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.