Other·May 5, 2022

F825 42 CFR §483.65 Specialized rehabilitative services. §483.65(a) Provision of services. If specialized rehabilitative services such as but not limited to physical therapy, speechlanguage pathology, occupational therapy, respiratory therapy, and rehabilitative services for mental illness and intellectual disability or services of a lesser intensity as set forth at §483.120(c), are required in the resident’s comprehensive plan of care, the facility must— §483.65(a)(1) Provide the required services; or §483.65(a)(2) In accordance with §483.70(g), obtain the required services from an outside resource that is a provider of specialized rehabilitative services and is not excluded from participating in any federal or state health care programs pursuant to section 1128 and 1156 of the Act. 22 CCR §72311. Nursing Service - General. (a)Nursing service shall include, but not be limited to, the following (1) Planning of patient care, which shall include at least the following: (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. 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 2/23/2022, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint about Resident 1’s quality of care and death. The facility failed to ensure Resident 1 maintained parameters of acceptable nutrition and hydration and had adequate food and fluid intake by not: 1. Providing Resident 1 with a speech therapist (a medical practitioner who can determine the presence and severity of person's difficulty in swallowing) evaluation, per the care plan and physician's order. 2. Accurately monitoring and assessing Resident 1's nutritional intake (food and liquids consumed) to ensure the resident consumed at least 50% each meal as indicated in the care plan. 3. Notifying Resident 1’s attending physician the resident was refusing food and frequently consuming less than 50% of meals. 4. Reviewing, evaluating, and updating Resident 1’s care plan interventions to address the resident's weight loss. 5. Conducting an interdisciplinary team (IDT, a group of healthcare professionals from different disciplines [nurses, social worker, therapist, physician, etc.] involved in the resident’s care) conference or weight variance committee meeting to manage Resident 1's weight loss, as indicated in the facility’s policy. As a result, by 4/18/2021, nine weeks after admission (2/13/2021), Resident 1 sustained a progressive severe weight loss of 16.8 lbs., equivalent to a loss of 13.46% of the resident’s body weight. On 4/21/2021 at 1:21 AM, Resident 1 was transferred to the General Acute Care Hospital 1 (GACH 1) emergency room (ER) due to tachycardia (increased heart rate) where he expired at 1:57 AM (36 minutes from time of transfer). A review of Resident 1's Admission Record (Face Sheet) indicated the facility admitted the resident, an 80-year-old male, on 2/13/2021, with diagnoses including Stage IV pressure ulcer (a very deep bedsore [also called pressure ulcer, damage to an area of the skin caused by constant pressure on the area for a long time] reaching into muscle and bone), dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), Type II diabetes mellitus (chronic condition that affects the way the body processes blood sugar [glucose]), and mild protein-calorie malnutrition (occurs when a person does not eat enough protein and energy [measured by calories] to meet nutritional needs). A review of the Physician's Order for Resident 1, dated 2/13/2021, indicated to give a controlled carbohydrate (CCHO - a diet consisting of the same amount of carbohydrates every day) mechanical soft diet (a texture-modified diet that restricts foods difficult to chew or swallow). A review of Resident 1's History and Physical exam (H&P), completed by the attending physician on 2/16/2021, indicated the resident was admitted to the facility for wound care and the resident did not have the capacity to understand and make decisions. A review of Resident 1's Weight Log indicated the resident’s weight a day after admission (2/14/2021) was 124.8 lbs. On 2/21/2021 (a week after admission) Resident 1 weighed 117 lbs. a severe weight loss of 7.8 lbs., equivalent to 6.25% of his body weight. A review of Resident 1's initial Minimum Data Set (MDS, a comprehensive assessment and care-planning tool) dated 2/20/2021, indicated Resident 1 never / rarely made decisions, had little interest or pleasure in doing things, felt down, depressed or hopeless and had trouble sleeping two to six days of the week. Resident 1 required total care, was dependent on staff for toileting and personal hygiene and required extensive assistance with one-person physical assist with eating. According to a review of Resident 1’s Certified Nursing Assistant (CNA) Activities of Daily Living (ADL) flowsheet for 2/2021, in the first two weeks from admission, (2/13/2021 to 2/28/2021), the resident ate between 0% to 50% of 12 of 15 breakfast meals. From 2/19/2021 thru 2/21/2021, Resident 1 ate 60% to 80% of his breakfast meals and 0% to 50 % 12 of 15 lunch meals. Resident 1 ate 0% to 50% of all dinner meals. A review of Resident 1's Physician's Orders, dated 2/23/2021, indicated: - Evaluation by speech therapist (ST – health professionals that work to prevent, assess, diagnose, and treat speech, language, social communication, cognitive-communication, and swallowing disorders in children and adults) - Evaluation by a registered dietician (RD - health professionals that assess, diagnose, and treat dietary and nutritional problems) - Encourage hydration (the process of providing an adequate amount of liquid to bodily tissues) and nutrition (eating a healthy and balanced diet). - Provide fortified (extra nutrients added) mechanical soft diet and to give eight ounces (oz) high protein nutrition (HPN) three times daily with meals. A review of the Situation- Background - Assessment and Response (SBAR – communication technique that facilitates communication between members of the health care team about a patient's condition) Change of Condition form, dated 2/28/2021, indicated Resident 1 refused breakfast and lunch for three days. A review of Resident 1's Care Plan developed on 2/28/2021 for the resident’s risk of weight loss, indicated Resident 1 had a body weight twenty percent or more under ideal weight. The interventions included helping as necessary, maintaining intake and output log as indicated, offering fluids frequently, providing education to resident, responsible party, and staff regarding special care needs, and referring to a speech therapist consult as needed. A review of Resident 1's nursing Progress Notes from 3/1/2021 through 3/4/2021. indicated the resident was monitored for poor appetite. A review of Resident 1's SBAR form dated 3/8/2021, indicated Resident 1 ate 30% of breakfast and 40% of lunch, indicating poor intake. According to a review of Resident 1's Weight Log the following weights were documented: - On 3/14/2021, 113 lbs. (11.8 lbs. weight loss in one month, a severe weight loss) - On 3/28/2021, 110.5 lbs. (14.3 lbs. weight loss in six weeks) - On 4/11/2021, 109 lbs. (15.8 lbs. weight loss in nine weeks) - On 4/18/2021, 108 lbs. (16.8 lbs. a severe weight loss in nine weeks or 13.46% loss of body). A review of the Physician's Orders for Resident 1, dated 3/8/2021, indicated to give intravenous (IV) hydration on 3/8, 3/11, 3/15, 3/18, 3/22, 3/26, 3/29/2021, 4/2, 4/11, and 4/20/2021. A review of Resident 1's IDT conference notes, dated 3/25, 3/31 and 4/7/2021, indicated the IDT met to evaluate Resident 1's pressure sore on his tailbone region. The IDT conference summary notes indicated the resident had poor oral intake but did not recommend new interventions for the weight loss. A review of the Physician's Order for Resident 1, dated 4/6/2021, indicated to provide the resident with a protein shake and water every hour. A review of Resident 1’s nursing Progress Notes, dated 4/21/2021 timed at 1:21 AM indicated Resident 1 was transferred to GACH 1 ER due to tachycardia 150 beats per minute (normal range is between 60-100), shortness of breath, with the oxygen saturation (the amount of oxygen circulating in the red blood normal range above 95%) measuring 69% on room air (without oxygen administration), the respiratory rate at 29 breaths per minute (normal rate is 16-18). A review of GACH 1 ER documentation indicated on 4/21/2021, at 1:57 AM (36 minutes from the time of transfer) Resident 1 expired. A review of Resident 1's Certificate of Death indicated Resident 1 expired on 4/21/2021 at 1:57 AM. The causes of his death were respiratory failure, coronary artery disease and Alzheimer's dementia. On 3/22/2022 at 11:40 AM, during an interview, Licensed Vocational Nurse 1 (LVN 1) stated Resident 1’s weight was monitored, CNAs documented the food and nourishment intake on the CNA ADL flowsheets. The nourishment included snacks, health, and protein shakes. LVN 1 stated if a resident's intake went down to 50%, this was an alert and staff needed to get the RD and the physician involved. On 3/22/2022 at 1:08 PM, during an interview, Registered Nurse 1 (RN 1) stated upon admission, the resident was weighed weekly for four weeks. RN 1 stated it was important to monitor the resident's weight. "When a resident loses weight, we first notify the doctor or nurse practitioner (NP) and get an order for an RD consult. If a resident continues to lose weight, the IDT will meet in conjunction with the family to form a plan to stop the resident's weight loss. We have to revise the care plan and make another intervention in a week if they continue to lose weight." On 3/24/2022 at 11:40 AM, during an interview and record review, LVN 2 stated there was no documentation that the doctor was informed of Resident 1’s weight loss. LVN 2 stated Resident 1's weight loss should have been care planned, reviewed and updated, when his weight continued to drop. When the resident continued to lose weight, "we should have kept trying different interventions." After reviewing the weight loss care plan, developed on 2/28/2021, LVN 2 stated if there was a review, a date would be listed. LVN 2 stated that the weight variance committee should have become involved in this case. On 3/24/2022 at 2:10 PM, during an interview with the Director of Nursing (DON) and concurrent review of Resident 1's clinical record, the DON stated on 2/21/2021 the resident’s weight was close to 80 lbs. and there were no nursing progress notes about the weight loss. The DON stated she could not find a ST evaluation ordered by the physician for Resident 1’s swallowing abilities. The DON stated it was important to update the care plan interventions to ensure the care plan was effective. While reviewing the policy on nourishment percentage documentation, the DON stated, “It would be important to know exactly how much the resident is taking in and not just generalities." When asked about the lack of documentation that Resident 1 was offered protein shake and water every hour per the physician’s order, the DON was unable to answer. During a telephone interview on 3/25/2022 at 11:05 AM, , RD 1 stated, "If a significant weight change happened, there will be a weight variance and the DON, supervisor, social services, and others will discuss the weight change, and I will make recommendations. The weight variance committee should be analyzing the interventions taking place because the resident could continue to experience weight loss and we don't want the resident to get weaker." On 3/28/2022 at 1:08 PM, during an interview, Family Member 1 (FM 1) stated the facility did nothing to address the resident's weight loss, she was not informed the resident was refusing to eat or needed to be fed. FM 1 stated, "When I was there, the CNA would drop his evening meal and leave. I would make sure he had the Ensure (nutritional supplement), he would drink it all and sometimes more than one can if he was hungry. His roommate would tell me that he needed to be fed." FM 1 stated the plan for Resident 1 was to get wound care at the facility and return home. FM 1 stated, "He was skeletal when he died. I am angry. I am just angry." A review of the facility’s policy and procedure titled, "Meals - Serving between Meal Nourishment," revised 1/1/2012, indicated the percentage of nourishment consumed was recorded in the resident's medical record and to update the resident's care plan as necessary. A review of the facility’s policy and procedure titled, "Nutritional Status Evaluation Committee," revised 6/2018, indicated its purpose was to ensure the physical well-being of residents through the management of weight variance. The resident's weight would be monitored for variance and the Nutritional Status Evaluation Committee would intervene when appropriate. Residents with 2% weight change in one week, 5% and/or 5 lbs. weight change in one month, or 7.5% weight change in three months may be included on the list for discussion. Residents on the list would be reviewed monthly until their weight has stabilized. Objectives of the nutritional status evaluation committee included identifying medical or pharmacological conditions, which may be affecting weight changes; evaluating changes in diet, identifying residents with signs of dysphagia (chewing or swallowing problems) for proper intervention and diet modification; and identifying behaviors in the feeding environment that may be contributing to weight loss. A review of the facility’s policy and procedure titled, "Food and Fluid Percentage Documentation," revised 8/11/ 2020, indicated the CNA will record the percentage of all food and fluid intake in the Resident's ADL flowsheet after each meal. The documentation of nourishment percentages between meals consumed by the resident will be recorded in the resident's ADL flowsheet. A review of the facility’s policy and procedure titled, "Evaluation of Weight & Nutritional Status," revised 1/2019, indicated any resident’s weight that varies from previous reporting period by 5% in 30 days, 7.5 % in 90 days, 10% in 180 days, will be evaluated by the IDT - Nutrition & Weight Variance Committee to determine the cause of weight loss and the intervention(s) required. Once weight loss as described above was identified, the IDT - Nutrition and Weight Variance Committee will identify and implement appropriate interventions; update and revise the Care Plan, as appropriate; notify the attending physician; and notify the registered dietician. When there was a weight variance of five pounds in one month, the weight loss will be evaluated by the IDT - Nutrition & Weight Variance Committee to determine the cause of and respond as appropriate. The facility failed to ensure Resident 1 maintained parameters of acceptable nutrition and hydration and had adequate food and fluid intake by not: 1. Providing