Health inspection·December 1, 2023

Code of Federal Regulations, Title 42, section 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. California Code of Regulations, Title 22, section 72315 - Nursing Service - Patient Care (h) Each patient shall be provided with good nutrition and with necessary fluids for hydration. California Code of Regulations, Title 22, section 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 10/16/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct its Annual Recertification Survey. The facility failed to ensure Resident 106 was provided with good nutrition to maintain acceptable parameters of nutritional status, and did not experience unplanned severe weight loss (greater than 5% in one month), as indicated in the facility’s policies, by not ensuring: 1. Resident 106 received gastrostomy tube (GT – a flexible tube surgically inserted through the abdomen into the stomach to administer nutrition and medications) feeding at the rate of 70 milliliters (ml) per hour (ml/hr.) in a 20-hour period for a total of 1600 ml or 2400 kilocalorie (Kcal - energy content of foods) in 24 hours, as ordered by the physician to meet the recommended daily nutrition intake. 2. Licensed nurses monitored and documented Resident 106’s fluid intake (through the GT) for four weeks as ordered by the physician and per facility’s policy. 3. Resident 106’s significant weight loss of 17 pounds (lbs.) in one month identified on 10/4/2023, was reported to the physician and to Registered Dietitian 1 (RD 1). 4. Resident 106’s GT feeding recommended by RD 1 on 10/10/2023 was promptly relayed to the physician and not four days later. As a result, Resident 106 experienced severe weight loss of 17 lbs. (equivalent to 13% of the resident’s body weight) between readmission on 9/5/2023 to 10/4/2023 which placed Resident 106 at risk for further weight loss and medical complications related to inadequate nutrition. A review of Resident 106’s Admission Record indicated the resident was originally admitted on 8/17/2023 and was readmitted on 9/5/2023 with diagnoses including GT (placed on 8/14/2023), and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to arms and legs). A review of Resident 106 Physician’s Orders upon readmission (9/5/2023) indicated the following orders: - Isosource 1.5 (brand of GT feeding formula) to provide 1200 ml (1800 Kcal) in 20 hr. via GT pump (a device that delivers the tube feeding formula with a set rate). Start infusion at 12:00 p.m. and turn it off at 8 a.m. Continue until the ordered volume is infused (administered). Set the pump at 60 ml/hr. - Monitor intake and output and output (urine) for four weeks then reevaluate. A review of Resident 106’s RD Assessment (RDA) Form, dated 9/8/2023, indicated Resident 106’s body mass index (BMI - tool healthcare providers use to estimate the amount of body fat using the person’s height and weight; BMI less than 18.5 is considered underweight) was 18.1. Resident 106’s ideal body weight (IBW) range was 154 to 172 lbs. but Resident 106’s weight was 130 lbs., below the IBW. The goal was to gradually gain weight. RD 1 documented Resident 106 did not have edema (swelling). RD 1 documented Resident 106 may benefit from additional Kcals, protein supplements. A review of Resident 106’s Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated 9/12/2023, indicated Resident 106 had a severely impaired cognition (ability to think and make decisions) and required total care. Resident 106’s height was 71 inches and weighed 130 lbs. Resident 106 was on a mechanically altered diet (pureed) and GT feeding. A review of Resident 106’s Weekly Weights Record were as followed: - 9/6/2023, 130 lbs. (readmission weight) - 9/13/2023, 126 lbs. (three lbs. of weight loss in seven days) - 9/20/2023, 123 lbs. (seven lbs. of weight loss in 14 days) - 9/27/2023, 120 lbs. (10 lbs. of weight loss in 21 days) - 10/4/2023, 113 lbs. (17 lbs. of total weight loss in 28 days) A review of RD 1 recommendations dated 10/10/2023, included in addition to dietary supplements, increasing Isosource 1.5 to 70 ml/hr. for 20 hours to provide a total of 1400 ml or 2100 Kcal. A review of Resident 106 Physician’s Order, dated 10/14/2023, indicated to increase Isosource 1.5 to 80 ml/hr. to run for 20 hours to provide 1600 ml or 2400 Kcal via enteral feeding (tube feeding). On 10/17/2023 at 8:25 a.m., during an observation of Resident 106 in bed and concurrent interview, Registered Nurse 1 (RN 1) stated the GT feeding was ongoing and the rate of Resident 106’s GT feeding was set at 60 ml/hr. On 10/17/2023 at 8:29 a.m., during an interview with RN 1 and concurrent review of Resident 106’s Medication Administration Record (MAR) for 10/2023, RN 1 stated GT feeding rate should have been set to 70 ml/hr. not the observed 60 ml/hr. On 10/18/2023 at 9:22 a.m., during an interview with Licensed Vocational Nurse 2 (LVN 2) and concurrent review of Resident 106’s medical record, indicated there was no documentation of Resident 106’s daily intake of GT feeding from 9/5/2023 to 10/18/2023. LVN 2 stated the attending physician ordered to monitor Resident 106’s intake on 9/5/2023. LVN 2 stated that it was also the facility’s policy that for any newly admitted resident with GT feeding staff was to monitor the resident’s intake and output for one month. LVN 2 stated the policy and the physician’s order were not followed. On 10/18/2023 at 1:44 p.m., during an interview with RD 1 and concurrent review of Resident 106’s RDA Form from 9/4/2023 to 10/18/2023, RD 1 stated that Resident 106 was assessed on 9/8/2023 and there were no other RD assessments conducted until 10/10/2023. After reviewing the physician’s orders for Resident 106 dated 10/14/2023, RD 1 stated the dietary recommendations she gave on 10/10/2023 were not carried out (relayed to the physician to obtain orders) until 10/14/2023. RD 1 recommendations should be implemented immediately to help prevent further weight loss and malnutrition. On 10/19/2023 at 8:10 a.m., during observation of Resident 106’s GT pump rate with LVN 1 and concurrent interview, LVN 1 stated the total volume administered to Resident 106, as calculated by the GT pump at the time of observation, was 1081 ml in the past 24 hours and not the 1600 ml as ordered by the physician. LVN 1 stated the feeding pump was likely stopped throughout various times. On 10/19/2023 at 10:00 a.m., during an interview, RD 1 stated the licensed nurses should check the total volume of GT feeding administered to the resident before turning it off. RD 1 stated that if the total volume of the GT feeding does not reach the ordered amount the GT should still be continued within a 24-hour period. RD 1 stated that the total volume and Kcal ordered is important for residents to maintain or prevent weight loss. On 10/19/2023 at 11:01 a.m., during an interview, LVN 1 stated she turned off Resident 106’s GT feeding since approximately 9:40 a.m. and Resident 106 did not receive the full amount of GT feeding (1600 ml or 2400 Kcal) as ordered by the physician. After reviewing Resident 106’s weekly weight from 9/5/2023 to 10/4/2023, LVN 1 stated that on 10/4/2023, Restorative Nursing Assistant 1 (RNA 1) notified her about Resident 106’s weight loss of 17 lbs. LVN 1 stated that she did not notify Resident 106’s physician or RD 1 because she forgot. LVN 1 stated she should have also notified the RN Supervisor. LVN 1 acknowledged Resident 106 was placed at risk for further weight loss and malnutrition. On 10/19/2023 at 11:10 a.m., during an interview, the Director of Nursing (DON) Stated that for newly admitted residents with GT, the intake is to be monitored according to the facility’s policy on Intake and Output. The DON stated that since admission, Resident 106 had been progressively losing weight, approximately three to four lbs. per week. Resident 106’s physician should have been notified as soon as possible for any weight loss of 3% or 3 lbs. or more each week to assess for possible underlying conditions and develop interventions to address the weight loss, as with no interventions in place, Resident 106 would lose more weight. The DON stated RD 1 should have assessed Resident 106 on 10/4/2023 when the resident had exhibited severe weight loss. During a concurrent interview and record review on 10/19/2023 at 11:10 a.m., with DON, Resident 106’s RDA Form from 9/4/2023 to 10/18/2023 were reviewed, and Resident 106’s physician orders dated 10/14/2023 were reviewed. The DON stated that Resident 106 experienced a delay in care of approximately 10 days. The DON stated that the facility was first made aware of Resident 106’s severe weight loss on 10/4/2023, RD 1’s recommendations dated 10/10/2023 were not ordered for Resident 106 until 10/14/2023. A review of the facility’s policy and procedure (P&P) titled, “Enteral Feeding” last reviewed by the facility on 2/22/2023, indicated all personnel responsible for administering enteral nutrition formulas will be trained, qualified and competent in his or her responsibilities. To prevent errors in administration, check the enteral nutrition label against the order before administration including rate of administration ml/hr. A review of the facility’s P&P titled, “Weight Assessment and Interventions” last reviewed by the facility on 2/22/2023, indicated the multidisciplinary team would strive to prevent, monitor, and intervene for undesirable weight loss for their residents. Any weight change of 5% or more, nursing will immediately notify the dietitian in writing. Verbal notification must be confirmed in writing. The dietitian will respond within 24 hours of receipt of written notification. One month 5% weight loss is significant; greater than 5% is severe. A review of the facility’s P&P titled, “Intake and Output” the facility last reviewed by the facility on 2/22/2023, indicated intake and output monitoring will be initiated by the licensed nurse or as ordered by the physician. Intake and output measurement will be performed on all residents with enteral feedings. Nursing assistant and licensed nurse will document the resident’s intake and output on the Intake and Output Form in the resident’s medical record. A review of the facility’s P&P titled, “Nutritional Assessment”, last reviewed by the facility on 2/22/2023, indicated the dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutrition assessment for each resident upon admission (within current baseline assessment timeframes) and as indicated by a change in condition that places the resident at risk for impaired nutrition. The facility failed to ensure Resident 106 was provided with good nutrition to maintain acceptable parameters of nutritional status, and did not experience unplanned severe weight loss (greater than 5% in one month), as indicated in the facility’s policies, by not ensuring: 1. Resident 106 received GT feeding at the rate of 70 ml/hr in a 20-hour period for a total of 1600 ml or 2400 Kcal in 24 hours, as ordered by the physician to meet the recommended daily nutrition intake. 2. Licensed nurses monitored and documented Resident 106’s fluid intake for four weeks as ordered by the physician and per facility’s policy. 3. Resident 106’s significant weight loss of 17 lbs. in one month identified on 10/4/2023, was reported to the physician and to RD 1. 4. Resident 106’s GT feeding recommended by RD 1 on 10/10/2023 was promptly relayed to the physician and not four days later. As a result, Resident 106 experienced severe weight loss of 17 lbs. (equivalent to 13% of the resident’s body weight) between readmission on 9/5/2023 to 10/4/2023 which placed Resident 106 at risk for further weight loss and medical complications related to inadequate nutrition. The above violations jointly, separately, or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 106.