Health inspection·March 20, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, staff interview, and review of facility policies, the facility failed to ensure a physician was notified when the facility was unable to administer a resident's enteral nutrition as ordered. This affected one (#38) of two residents reviewed for tube feeding. The facility census was 28. Findings include: Review of the medical record revealed Resident #38 had an admission date of 02/12/24 and a discharge date of 02/20/24. Diagnoses included end stage renal disease, liver disease, autoimmune hepatitis, depression, generalized anxiety disorder, dysphagia, gastrostomy status, and liver transplant status. Review of the Minimum Data Set (MDS) five-day assessment dated [DATE] revealed Resident #38 had intact cognition. The resident required set-up assistance for meals and had a feeding tube. Review of hospital discharge orders dated 02/12/24 revealed Resident #38 had orders for Jevity 1.5 (nutritional formula) at 20 milliliters (ml) per hour by percutaneous endoscopic gastrostomy (PEG) tube. Review of a physician order dated 02/12/24 revealed Resident #38 had orders for enteral feed continuous Jevity 1.5 at 20 milliliters (ml) per hour. Review of Resident #38's medication administration record from 02/12/24 through 02/15/24 revealed there was no documentation that the resident received the Jevity 1.5 enteral feed. Review of Resident #38's nursing notes from 02/12/24 through 02/15/24 revealed no documentation the physician was notified the enteral feed was not administered. Review of a medication note dated 02/14/24 at 4:01 A.M. revealed the facility was awaiting delivery of feed and pump. Interview on 03/20/24 at 10:44 A.M., with Registered Nurse (RN) #124 revealed Resident #38 was admitted with orders for continuous PEG tube feeding. RN #124 revealed the resident's family brought in the nutritional formula for the tube feeding. RN #124 revealed the pump required to administer the tube feeding was not working and a new one was ordered. RN #124 was not sure when the new pump arrived. RN #124 further revealed she believed by the time the new pump arrived the resident had already been changed to bolus PEG tube feedings. Interview on 03/20/24 at 10:55 A.M., with the Director of Nursing (DON) verified Resident #38 had Page 1 of 4 366081 366081 03/20/2024 Parkview Care Center 1406 Oak Harbor Rd Fremont, OH 43420

F 0580 Level of Harm - Minimal harm or potential for actual harm not received continuous tube feeding from 02/12/24 through 02/15/24. The DON revealed it could have been because the facility did not have the pump. The DON emailed and called the service provider for the pump delivery date but at the time of exit the DON had not heard back from the service provider. The DON verified the physician was not notified when the enteral feed pump was unavailable. The DON revealed the physician should have been notified for a new order for bolus feedings when the pump was not available. Residents Affected - Few Review of the policy titled, Enteral Tube Feeding via Continuous Pump, revised 11/18, revealed to report complications promptly to the supervisor and attending physician. Review of the policy titled, Change in a Resident's Condition or Status, revised 02/21, revealed the nurse would notify the physician when there was a need to alter the resident's medical treatment significantly and the nurse would document in the resident's medical record information relative to changes in the resident's medical/mental condition or status. 366081 Page 2 of 4 366081 03/20/2024 Parkview Care Center 1406 Oak Harbor Rd Fremont, OH 43420

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, staff interview, and policy review, the facility failed to ensure a resident received enteral feedings per physician orders. This affected one (#38) of two residents reviewed for tube feedings. The facility census was 28. Findings include Review of the medical record revealed Resident #38 had an admission date of 02/12/24 and a discharge date of 02/20/24. Diagnoses included end stage renal disease, liver disease, autoimmune hepatitis, depression, generalized anxiety disorder, dysphagia, gastrostomy status, and liver transplant status. Review of the Minimum Data Set (MDS) five-day assessment dated [DATE] revealed Resident #38 had intact cognition. The resident required set-up assistance for meals and had a feeding tube. Review of hospital discharge orders dated 02/12/24 revealed Resident #38 had orders for Jevity 1.5 (nutritional formula) at 20 milliliters (ml) per hour by percutaneous endoscopic gastrostomy (PEG) tube. Review of a physician order dated 02/12/24 revealed Resident #38 had orders for enteral feed continuous Jevity 1.5 at 20 milliliters (ml) per hour. Further review of the physician orders revealed the resident was ordered a regular diet with regular texture and thin liquids with a 1500 ml fluid restriction. Review of Resident #38's medication administration record (MAR) from 02/12/24 through 02/15/24 revealed there was no documentation the resident received the enteral feed. Review of a physician order dated 02/16/24 revealed Resident #38's enteral feed order was changed. The resident was ordered an enteral feed every four hours as needed for tube feeding with a 100 ml bolus if less than 50 percent (%) a of meal was consumed. The type of nutritional formula was not specified in the order. The resident was also ordered 100 ml water flushes three times a day. Review of Resident #38's meal intake log from 02/16/24 through 02/20/24 revealed on 02/17/24 and 02/19/24 the resident consumed less than 50% of her lunch and dinner meals. Review of the MAR for 02/17/24 and 02/19/24 revealed Resident #38 was not administered the as needed bolus feedings when she consumed less than 50% of her lunch and dinner meals. Further review of the documentation revealed the resident had not refused the bolus feedings on 02/17/24 and 02/19/24. Interview on 03/20/24 at 10:44 A.M., with Registered Nurse (RN) #124 revealed Resident #38 was admitted with orders for continuous tube feeding. RN #124 revealed the resident's family brought in the nutritional formula for the tube feeding. RN #124 revealed the pump required to administer the tube feeding was not working and a new one was ordered. RN #124 was not sure when the new pump arrived. RN #124 further revealed she believed by the time the new pump arrived the Resident #38's enteral feeding order had already been changed to bolus feedings. 366081 Page 3 of 4 366081 03/20/2024 Parkview Care Center 1406 Oak Harbor Rd Fremont, OH 43420

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 03/20/24 at 10:55 A.M., with the Director of Nursing (DON) verified there was no documentation that Resident #38 was administered enteral feedings from 02/12/24 through 02/15/24. The DON also verified there was no documentation the resident was administered the as needed bolus feedings on 02/17/24 and on 02/19/24 when Resident #38 consumed less than 50% of lunch and dinner meals on those days. The DON verified there was no documentation the resident refused the bolus feedings on 02/17/24 and 02/19/24. Review of the policy titled, Enteral Tube Feeding via Continuous Pump, and review of the policy titled, Enteral Tube Feeding via Syringe (Bolus), both policies revised on 11/18, revealed to verify physician orders before administering and document the amount of feeding and amount of water administered and if the resident refused the procedure the reason why along with all assessment data. This deficiency represents non-compliance investigated under Complaint Number OH00151342. 366081 Page 4 of 4