Health inspection·July 8, 2021

Title 22 §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. F692 §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- §483.25(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 indicate otherwise; §483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health; §483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet. On 5/7/2021, an unannounced visit was made to the facility to investigate a complaint about quality of care. The facility failed to ensure Resident 1 received between 1620-1890 milliliters (ml- a unit of measurement) per day of fluid needed to maintain proper hydration and health. As a result, on 4/10/2021, Resident 1 developed increased confusion, low blood pressure (hypotension) 100/40 millimeters of mercury (mmHg - normal range between 90/60 and 120/80 mmHg), and low heart rate (bradycardia) 48 beats per minute. Resident 1's baseline was unknown (normal 60-100 beats per minute [bpm]). Resident 1 required transfer to General Acute Care Hospital 2 (GACH 2), where she was diagnosed with severe dehydration (a dangerous loss of body fluid caused by illness, sweating, or inadequate intake of fluid which could result in confusion and weakness as the brain and other body organs receive less blood flow), and urinary tract infection (UTI- an infection in any part of the urinary system: kidneys, bladder, or urethra). A review of Resident 1's Admission Record (Face Sheet) indicated the facility admitted Resident 1, an 86-year old female on 3/9/2018 with a readmission dated 4/15/2020 with diagnoses including metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood caused by an illness or organs that are not working as well as they should), kidney failure, hypernatremia (medical term used to describe having too much sodium in the blood occurs due to net water loss or excess sodium intake [dehydration]) and hyperosmolality (high concentration of chemical particles the fluid part of blood, usually associated with hypernatremia [high sodium level related to dehydration]), and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and dementia (mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems). A review of Resident 1's Physician's Order, dated 10/15/2020, indicated to provide fortified (with added nutrients) mechanical dysphagia (difficulty swallowing) texture diet (consist of foods that can be safely and successfully swallowed. Foods are mechanically altered by whipping, blending, grinding, chopping, or mashing so that they are easy to chew and swallow) and thin liquids consistency. A review of Resident 1's Risk for Nutritional Problem Care Plan, developed on 11/20/2020 (with no revision date), due to poor oral intake, had a goal for Resident 1 to maintain adequate nutritional status. A review of Resident 1's Risk for Dehydration Care Plan developed on 11/20/2020 (with no revision date), due to medications side effects and poor oral intake, had a goal for Resident 1 to be free of symptoms of dehydration. The interventions included providing cold water, thickened apple sauce, invite resident to activities that promote additional fluid intake, monitor and document intake and output, monitor vital signs (measurements of the body's most basic functions such as body temperature, heart and respiration rate, and blood pressure), and monitor, document, and report to the physician, signs and symptoms of dehydration: decreased or no urine, concentrated urine, strong other tenting skin, cracked lips, furrowed tongue, new onset of confusion, dizziness on increased pulse, headache, fatigue, weakness, dizziness, fever, thirst, recent/sudden weight loss, and dry/sunken eyes. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 3/30/2021, indicated Resident 1 was unable to remember, make decisions, or make needs known. Resident 1 required extensive assistance with eating (needed to be assisted by one staff to eat), toilet use, personal hygiene, and bathing. Resident 1 had dysphagia at the oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat) and was on a mechanically altered therapeutic diet. A review of Resident 1's Physician's Order dated 3/15/2021, indicated a change of the diet from fortified mechanical soft to fortified pureed texture diet with thin liquids consistency. A review of Resident 1's Dietary Nutritional Progress Note, dated 4/1/2021, Registered Dietician (RD) indicated the last albumin test was dated 2/17/2021 which was low, 3.2 g/dl. The RD documented Resident 1's estimated fluid needs were between 1620-1890 ml per day; however, the RD did not evaluate Resident 1's daily fluid intake to determine if Resident 1 was consuming sufficient fluids. A review of Resident 1's Health Status Note (Nursing Note) dated 4/10/2021, timed at 9:03 a.m., indicated at approximately 8:15 a.m., the resident had three episodes of vomiting, increased confusion, blood pressure 100/40 mmHg (low), and heart rate of 48 bpm (low). The attending physician was notified and ordered a non-emergency transfer to GACH 1 for further evaluation. Resident 1 desaturated (developed a sudden low oxygen saturation - oxygen carried by the red blood cells to all the body organs and tissues, the normal oxygen saturation over 95%) with oxygen saturation reading of 81%, the heart rate increased to 110 bpm, and the blood pressure was 140/60 mmHg. Paramedics (health care professionals whose primary role is to provide advanced emergency medical care for critical and emergent patients) were called (911 call) and arrived at 9:20 a.m. Paramedics transferred Resident 1 at 9:37 a.m. to GACH 2 (closer to the facility). A review of Resident 1's GACH 2's Intensive Care Unit (ICU) Consultation Note, dated 4/10/2021, timed at 1:38 p.m. indicated Resident 1 was admitted to GACH for hypernatremia. Resident 1 presented to GACH 2 with low oxygen saturation and was found to have severe hypernatremia with a sodium (Na) level of 172 milliequivalents per liter (mEq/L - unit of measure, normal blood sodium level is between 135 and 145 mEq/L). Resident 1 had "dehydration, acute renal failure, sinus tachycardia (rapid heartbeat), UTI (urinary tract infection) per lab test, and hypoxia (low oxygen in the blood). Resident 1's BUN (blood, urea, nitrogen, a measure of how much waste product is in blood and can indicate dehydration) was elevated at 41 mg/dL (normal range is 6 to 23 mg/dL), albumin was 2.8 gm/dL (normal range is 3.4 to 5.0 g/dL)." On 6/14/2021, at 8:47 a.m., during an interview, the Dietary Manager (DM) stated fluids provided with a meal tray included water, milk, and juice, coffee, hot cocoa. The DM stated a bedside water pitcher may contain varied amounts of water, with capacity to hold approximately 900 ml when full. The DM states it was the responsibility of the nurses to fill up the water pitchers and provide fluid to the residents. On 6/15/2021 at 10:59 a.m., during an interview with the Assistant Director of Nursing (ADON) and concurrent review of Resident 1's average fluid daily intake from 3/1/2021 to 4/10/2021, indicated the resident consumed between 240 to 720 ml/day, below Resident 1's estimated fluid needs of 1620-1890 ml/day recommended by Registered Dietitian. ADON could not explain why no new interventions were implemented to address the low fluid intake. ADON was unable to provide documentation the dehydration care plan intervention were implemented and if Resident 1 was assessed for signs and symptoms of dehydration. On 6/18/2021, at 2:26 a.m. during an interview with ADON and concurrent record review of Resident 1's medical record, the ADON stated neither the RD or the attending physician ordered laboratory tests for Resident 1, after 2/17/2021, to evaluate the resident's nutritional or hydration status. A review of the facility's policy and procedures titled, "Nutritional Assessment," revised date 8/21/2020, indicated to reassess a resident's dietary needs. The Registered Dietitian is responsible for completing ...laboratory data estimated nutritional needs...In the resident's medical record, the registered dietitian will provide the recommendations in narrative and identify any risk factors for weight loss or dehydration. This process will be repeated each time a nutritional assessment is required. A review of the facility's policy and procedures titled, "Resident's Rights - Quality of Life," revised date 3/2017, indicated to ensure that each resident receives the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. Each resident shall be cared for in a manner that promotes and enhances the quality of life... and receives services in a person-centered manner, as well as those that support the resident in attaining or maintain his/her highest practicable well-being. The facility failed to ensure Resident 1 received between 1620-1890 milliliters (ml- a unit of measurement) per day of fluid needed to maintain proper hydration and health. As a result, on 4/10/2021, Resident 1 developed increased confusion, low blood pressure (hypotension) 100/40 millimeters of mercury (mmHg - normal range between 90/60 and 120/80 mmHg), and low heart rate (bradycardia) 48 beats per minute. Resident 1's baseline was unknown (normal 60-100 beats per minute [bpm]). Resident 1 required transfer to General Acute Care Hospital 2 (GACH 2), where she was diagnosed with severe dehydration (a dangerous loss of body fluid caused by illness, sweating, or inadequate intake of fluid which could result in confusion and weakness as the brain and other body organs receive less blood flow), and urinary tract infection (UTI- an infection in any part of the urinary system: kidneys, bladder, or urethra). The above violations either jointly, separately, or in any combination presented either an imminent danger that death or serious harm would result or a substantial probability that death or serios physical harm would result to Resident 1.