Health inspection·July 26, 2022

The following reflects the findings of the California Department of Public Health during the investigation of Complaint number CA00700281. Representing the Department, HFEN 40747. State Citation B was written CLASS B CITATION - PATIENT CARE F 692 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 11/6/20, an unannounced visit was conducted at the facility to investigate a complaint of patient care. The facility failed to ensure Patient 1's decreased meal intake was identified, input and output was monitored, and nutritional supplement was provided as ordered by the physician. This resulted in Patient 1 sustaining a 13% weight loss and being transferred to the acute care hospital on 7/7/20 for dehydration and Lactic Acidosis (lactic acid build up in the bloodstream). Patient 1 was a 93 year-old male, admitted to the facility on 5/21/20. He had diagnoses that included Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movements such as shaking, stiffness, and difficulty with balance and coordination), Dementia (memory loss), and Dysphagia (difficulty swallowing). Patient 1 was on a mechanical soft (a texture-modified diet that restricts foods that are difficult to chew or swallow; examples include pureed, finely chopped, blended, or ground food) and low sodium (salt) diet. Patient 1 required supervision during meal times. During a review of the Minimum Data Set (MDS, an assessment tool used to guide care) dated 6/26/20, indicated Patient 1 required staff's assistance for set up and supervision during meals. During a review of Patient 1's Care plan titled, "Nutritional Status as evidence by potential weight loss related to inadequate oral intake ..." dated 5/27/20 indicated that the facility will "provide diet as ordered" and "review weights and notify the physician and responsible party of the significant weight change" During an interview on 1/31/22 at 1:35 p.m., with Director of Staff Development (DSD), DSD stated, Patient 1 was not eating and drinking sufficient amounts for Patient 1's pressure ulcer (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) to heal. During a review of Patient 1's Documentation Survey Report (DSR) Jun, Dated June 2020, indicated Patient 1 generally ate: 6/1/20 6/15/20 50% to 75% of meals and 6/16/20 6/29/20 0% to 25% of meals. During a review of Patient 1's DSR Jul, dated July 2020, indicated as follows regarding the percentage of meals Patient 1 ate: 7/1/20 0% of breakfast, 7/2/20 0% of breakfast, 7/3/21 refused breakfast, 0 % lunch, and 40% dinner, 7/5/20 0% for breakfast, 7/6/20 50% for breakfast, 25% for lunch, and 50% for dinner and 7/7/20 50% for breakfast and lunch. Review of the progress notes from 6/16/20 through 7/3/20 indicated there was no progress notes regarding Patient 1's decrease in meal intake until 7/3/20. A review of Patient 1's Nursing Progress Notes (NPN), dated 7/3/20, NPN indicated, " ...pt [patient] does not have much appetite consumed less than 25% of meals. . . staff continues to encourage fluids while awake..." During a review of Patient 1's NPN, dated 7/4/20, NPN indicated, " ...pt. does not have much appetite consumed less than 25% of meals. staff continues to encourage fluids while awake ..." During a review of Patient 1's NPN, dated 7/6/20, NPN indicated, "Alert and verbally responsive . . . encourage fluid and meal intake ... eat10% breakfast, 10% lunch, 25% dinner ...wt (164.6 lbs)...assessed by M.D..." During a review of Patient 1's "Order Summary Report" (OSR), dated 5/21/20 7/7/20, OSR indicated, "Weekly weight every day shift every Mon" was ordered on 5/22/20 and "Weekly weight every shift every Mon for monitoring" was ordered on 6/1/20. During a review of Patient 1's "Weights and Vitals Summary" (WVS), indicated Patient 1 weighed 182.2 lbs on 5/22/20, 189.2 lbs on 6/17/20 (Wednesday), and Patient 1 was next weighed on 7/6/20 (Tuesday), and weighed 164.6 pounds, a total of 24.6 lbs. (13%) weight loss within 20 days. During a review of Nutrition Assessment (NA), dated 5/27/20, NA indicated, " ...Encourage protein intake r/t [related to] wound healing. Plan/Monitor: ... continue to review wt [weight] trends, labs, and PO [by mouth] intake RD [Registered Dietitian] to f/u [follow up] PRN [as needed] Goal: Experience no significant wt [weight] changes." During a review of Patient 1's medical record, no additional Nutrition Assessments were found. During an interview on 2/8/22, at 9:30 a.m., with Registered Dietician (RD), RD stated, the registered dietician obtained information regarding Patient 1 in daily meetings with nursing staff and by reading Patient 1's chart. RD stated, if Patient 1 was ordered for strict I&O and weekly weights, and these were not done as ordered, the dietician should notify the doctor and nursing staff. RD stated, the dietician should have addressed issues regarding not eating and drinking adequate amounts. RD stated, Patient 1 should have been assessed monthly and more often, as needed, based on Patient 1's condition. RD stated, dietician, along with nursing, followed I&O, weights, and pressure ulcer status to assess the resident's condition and make recommendations, which the doctor would review and order if agreed. During a review of Patient 1's OSR, dated 5/21/20 7/7/20, indicated, "strictly monitor I&O (measure amount of liquid taken in and amount of liquid put out by resident) every shift for COVID 19," was ordered on 6/22/20. During a review of Patient 1's medical record (MR), MR revealed no recording of I&O, no recording of the amount of liquid Patient 1 took in and the amount of liquid he put out. During a review of Patient 1's "Order Summary Report" dated 5/21/2 7/7/20, indicated Patient 1 had the following orders: 1. 5/30/20 Low Sodium Cardiac Diet, Dysphagia, Mechanically Altered texture 2. 5/27/20 House shake two times a day with breakfast and lunch 3. 6/22/20 Strictly monitor input and output every shift During a review of Patient 1's Documentation Survey Report, dated June 2020, indicated the following dates and tasks were blank: For the section "Document Amount of Meal Taken": 6/3/20 breakfast and lunch, 6/12 lunch, 6/14 lunch, 6/19 breakfast and lunch, 6/20 dinner, 6/21 breakfast, lunch, and dinner, 6/25/ dinner, 6/26 lunch and dinner, 6/27 lunch and dinner, 6/28 breakfast, lunch, and dinner, 6/29 dinner, and 6/30/20 dinner. For the section "Nutritional Supplement": 6/3/20 8 am and noon, 6/12 noon, 6/19 8 am and noon, 6/21 8 am and noon, and 6/28/20 8 am and noon. For the section "HS (bedtime) Snack" 6/20/20, 6/21, 6/22, 6/24, 6/25, 6/26, 6/27, 6/28, 6/29, and 6/30/20, For the section "Hydration/Fluids Offered": 6/3/20 day shift and night shift, 6/7 night shift, 6/15 night shift, 6/21 night shift, 6/22 night shift, 6/24 night shift, 6/25 evening shift, 6/26 evening shift, 6/27 evening shift, 6/28 evening and night shift, 6/28 day, evening and night shifts, and 6/30/20 evening shift. During a review of Patient 1's Documentation Survey Report, dated July 2020, indicated staff had not charted for the following dates and tasks: For the section "Document Amount of Meal Taken": 7/1/20 lunch and dinner, 7/2 lunch and dinner, 7/4 breakfast, lunch, and dinner, and 7/5/20 lunch and dinner For the section "Nutritional Supplement": 7/4/20 8 am and noon, and 7/5/20 at 12 noon For the section "Hydration/Fluids Offered": 7/1/20 evening shift, 7/3 night shift, 7/4 day and evening shifts, 7/5 day and night shifts, and 7/6/20 night shift For the section "HS (bedtime) Snack": 7/1/20, 7/2, 7/4, and 7/5/20. During a review of MD Progress note, dated 6/29/20, indicated, "Continue encourage p.o [by mouth]. During a review of Patient 1's Nursing Progress Notes, dated 7/7/20, indicated, "patient transported via gurney to go to [acute care hospital] r/t related to] patient failure to thrive. pt not eating or drinking fluids, patient appears to be fatigue and has a persistent wet non productive cough, pt sent per MD order . . ." During a review of Patient 1's acute care hospital "Discharge Summary Note" (DS), dated 7/7/20, indicated Patient 1 was admitted to the hospital from the facility with significant dysphagia (difficulty swallowing), moderate protein calorie malnutrition, adult failure to thrive syndrome (a decline in older adults resulting in poor nutrition, weight loss, inactivity, depression and decreased functional ability), septic shock (a widespread infection causing organ failure and dangerously low blood pressure), hypernatremia (a high concentration of sodium in the blood usually caused by not drinking enough water) and COVID 19 positive. Review of the "Clinical Notes" section indicated Patient 1 had " ... LACTIC ACIDOSIS" (7/7/2020) potentially due to poor oral intake with recent 30# weight loss and associated dehydration markedly dry mucous membranes on exam ...being treated for septic shock." During a telephone interview on 2/8/22, at 12:57 p.m., with Director of Nursing (DON), DON stated, the doctor ordered strict I&O for Patient 1. DON stated, the liquids given to resident should have been recorded in milliliters (a measurement of volume. One milliliter was one thousandth of a liter.) DON stated, the number of times Patient 1 urinated should also have been recorded. DON stated, no documentation of I&O was in Patient 1's chart. DON stated, I&O would have shown the staff whether Patient 1 had sufficient fluids or was dehydrated. DON stated, Patient 1's charting should have been complete, so any change of condition could have been picked up and treated. During a telephone interview on 4/28/22 at 10:54 a.m., with DON, DON stated, the expectation was all doctor's orders were to be followed. DON stated, staff's failure to record Patient 1's I&O and weigh Patient 1 weekly may have contributed to his worsened condition. DON stated, the expectation was for staff to assess Patient 1, any change in his condition, and base his care on his condition. In violation of the above cited standards, the facility failed to ensure Patient 1 maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the patient's clinical condition demonstrates that this is not possible or patient preferences indicate otherwise; was offered sufficient fluid intake to maintain proper hydration and health; and was offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet, including but not limited to: the facility failed to ensure Patient 1's decreased meal intake was identified, input and output was monitored, and nutritional supplement was provided as ordered by the physician.