Other·September 3, 2021

F692 §483.25(g) Assisted nutrition and hydration 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 6/8/2021 an unannounced visit was made to the facility to investigate a complaint regarding quality of care and neglect. The facility failed to ensure Resident 1 maintained acceptable parameters of nutrition and hydration and had adequate food and fluid intake. The facility did not develop and implement interventions to assist Resident 1 with improving oral consumption of food and fluids and did not evaluate possible causal factors for the resident's poor oral intake. As a result, Resident 1's general condition deteriorated due to poor food and fluid intake, and on 5/7/2021, he required transfer to General Acute Care Hospital 1 (GACH 1). Resident 1 was diagnosed with sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death) and acute encephalopathy (disease in which the functioning of the brain is affected by some agent or condition such as viral infection or toxins in the blood) from an infectious process and placed the resident at risk for death. A review of Resident 1's Admission Record indicated the facility admitted the resident, a male, on 1/23/2021 with diagnoses including acute pyelonephritis (inflammation of the kidney due to bacterial infection), seizures (is a sudden, uncontrolled electrical disturbance in the brain), and type 2 diabetes (a chronic condition that affects the way the body processes blood sugar [glucose]). A review of Resident 1's Physician's Order dated 1/23/2021, indicated to give the resident a consistent carbohydrate diet/reduced concentrated sweet (CC/RCS-diet for diabetic people to manage their blood sugar levels and weight) regular texture, thin liquids consistency, eight-ounce juice, water with meals three times a day. A review of Resident 1's nutritional assessment dated 1/28/2021, indicated the resident's estimated daily needs based on a current weight of 159 pounds were 1800-2160 kilocalories, 72-86 grams of protein, and needed 2,160 milliliters (ml - fluid measurement) equivalent to 30 ml per kilograms (kg) to remain hydrated. A review of Resident 1's Interdisciplinary Team (IDT) meeting dated 4/11/2021, indicated the resident had a nine-pound weight loss related to decreased oral intake (poor eating). Resident was a candidate for weekly weights and needed more assistance from staff to eat. A review of Resident 1's Physician's Order dated 4/14/2021, indicated eight-ounce high protein nourishment (supplement) three times a day and fortified soup (have nutrients added) at lunch and dinner (twice a day) as supplement. The physician also ordered Megestrol acetate (appetite stimulant) give 10 milliliters (ml) by mouth, once a day for poor appetite for two weeks, if no improvement after two weeks, increase to twice a day and multivitamins once a day. A review of Resident 1's Care Plan, revised on 4/19/2021, indicated the resident was at nutritional (not consuming enough food) and dehydration (when a person uses or loses more fluid than her or she takes in, and the body does not have enough water and other fluids to carry out its normal function) risks secondary to weight loss/gain fluctuation, increased needs related to pressure ulcer ([also known as pressure sores or bedsores] are injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin), poor/variable intake and diagnosis. One of the goals was for the resident to consume at least 50-75% of each meal. The interventions included giving medications and diet as ordered and offering substitutes if intake is less than or equal to 75% of the meal. A review of Resident 1's Nutritional Assessment dated 4/24/2021, indicated Resident 1 had a score of seven, indicating malnourished (lack of sufficient nutrients in the body). A review of Resident 1's skin assessment dated 4/28/2021, indicated Resident 1 had an excoriation (scraped skin) on the sacrum (a triangular bone in the lower back, situated between the two hipbones) area. A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care-screening tool), dated 5/2/2021, indicated the resident had moderately impaired cognition (mental action of acquiring knowledge and understanding through thought and the senses). Resident 1 required extensive assistance with one-person personal assist with dressing, toilet use, and personal hygiene. Resident 1 needed limited assistance with one-person physical assist with eating. A review of Resident 1's Weight Summary form indicated the resident's weight was: - 159 pounds dated 3/2/2021, - 150 pounds on 4/9/2021 (a weight loss of nine pounds in one month and seven days. A review of Resident 1's Weekly Weight between 4/13/2021 and 5/5/2021, indicated the resident's weight fluctuated between 150 and 151 pounds. A review of Resident 1's Meal Percentage Intake documentation, from 4/29/2021 to 5/7/2021, indicated: On 4/29/2021 breakfast and lunch were 26-50%. Dinner was refused. On 4/30/2021 breakfast and dinner were refused. Lunch 0-25% On 5/1/2021 breakfast and dinner were 0-25 %. Lunch was refused. On 5/2/2021 breakfast and dinner were 0-25%. Lunch was refused. On 5/3/2021, 5/4/2021, and 5/5/2021, breakfast, lunch and dinner were 26-50% On 5/6/2021 breakfast and lunch were refused. Dinner was 26-50% On 5/7/2021 breakfast was 26-50% A review of Resident 1's snack percentage intake documentation, from 4/29/2021 to 5/6/2021, indicated: 4/29/2021 not applicable 4/30/2021 not applicable 5/1/2021 no documentation for both evening and night shift 5/2/2021 no documentation for both evening and night shift 5/3/2021 no documentation for both evening and night shift 5/4/2021 evening shift 25% eaten 5/5/2021 evening shift no documentation 5/5/2021 night shift not applicable 5/6/2021 evening shift no documentation 5/6/2021 night shift not applicable 5/6/2021 evening shift no documentation A review of Resident 1's Eating Performance from 4/29/2021 to 5/6/2021 indicated: - 4/29/2021 breakfast and lunch, Resident 1 was independent and no set up or physical help from staff, lunch, dinner, Resident 1 needed limited assistance with one-person physical assist. - 4/30/2021 for breakfast and lunch, Resident 1 needed limited assistance with one-person physical assist and for dinner, he needed supervision with setup help only. - 5/1/2021 for breakfast and lunch, Resident 1 needed limited assistance with setup help only. For dinner, resident 1 needed supervision with setup help only. - 5/2/2021 for breakfast and lunch, Resident 1 needed limited assistance with setup help only. For dinner, Resident 1 needed limited assistance with one-person physical assist. - 5/3/2021 for breakfast and lunch, Resident 1 needed limited assistance with setup help only. For dinner, Resident 1 needed limited assistance with one-person physical assist. - 5/4/2021 for breakfast and lunch, Resident 1 needed limited assistance with setup help only. For dinner, Resident 1 supervision and setup help only. -5/5/2021 for breakfast and lunch, Resident 1 needed limited assistance with setup help only. For dinner, Resident 1 was independent with setup help only. - 5/6/2021 for breakfast and lunch, Resident 1 refused, no documentation on dinner. - 5/7/2021 for breakfast, resident 1 needed extensive assistance with one-person physical assist. A review of Resident 1's Fluids with Meal documentation from 4/29/2021 to 5/29/2021, indicated the total fluids consumed per day were: On 4/29/2021, 420 ml. On 4/30/2021, 480 ml. On 5/1/2021, 530 ml. On 5/2/2021, 600 ml. On 5/3/2021, 600 ml. On 5/4/2021, 600 ml. On 5/5/2021, 1200 ml. On 5/6/2021, none (refused). On 5/7/2021, Resident 1 had 120 ml for breakfast. A review of Resident 1's Multidisciplinary Care Conference dated 5/4/2021, indicated, Family Member 1 (FM 1) was, "claiming resident has change in condition when she talked to him." A review of Resident 1's Progress Note dated 5/7/2021, indicated the resident was noted with increased weakness and poor intake by mouth. On 6/11/2021 at 3:10 p.m., during an interview, FM 1 stated on 4/29/2021, she called the Resident 1 over the telephone and he did not sound right. FM 1 stated she calls the resident daily but on that day, FM 1 could not understand what the resident said. FM 1 then called the nurse in charge and the nurse told her Resident 1 was fine. On 5/7/2021, when FM 1 went to visit the resident, he was lifeless. FM 1 had to alert the staff of the resident's condition and staff could not even take his blood pressure On 6/17/2021 at 1:29 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated on 5/7/2021, FM 1 told her Resident 1 was not well and was not eating. LVN 1 stated the resident was weak and had poor appetite and she notified Nurse Practitioner (NP). LVN 1 acknowledged not taking Resident 1's vital signs (reflect essential body functions, including your heartbeat, breathing rate, temperature, and blood pressure). NP ordered transfer (non-emergency) and when the regular ambulance came to pick Resident 1 up, the resident's blood pressure was low. 911 was called (call for immediate assistance by paramedics with transfer) and the resident was transferred GACH 1. On 6/17/2021 at 1:57 p.m., during an interview, Director of Nursing (DON) stated Resident 1's weakness and poor appetite since 4/2021 was a change of condition on the resident's status. On 6/17/2021 at 2:03 p.m., during an interview, Assistant DON (ADON) stated that on 5/7/2021, LVN 1 called her to assess Resident 1. ADON stated the regular ambulance staff found Resident 1's blood pressure to be low and the resident was unstable. ADON acknowledged not taking Resident 1's vital signs. ADON called the NP again and notified of the low blood pressure reading by the ambulance staff. NP ordered to transfer the resident via 911. On 6/24/2021 at 9:11 a.m., during an interview, NP stated she was notified of Resident 1's weakness and poor appetite on 5/7/2021 and ordered transferring the resident via regular ambulance (not via 911) because the information provided at the time of the call, did not include the resident's low blood pressure. On 7/20/2021 at 3:00 p.m., during an interview, Registered Dietitian 1 (RD 1) stated RD 2 evaluated Resident 1 on 4/15/2021. RD 1 stated since Resident 1 had continued loss of appetite and licensed nurses and RD should have monitored Resident 1 closely to ensure the resident's daily protein, fluid, and calorie needs were met. RD stated the resident's physician should have been notified of Resident 1's poor oral intake since 4/29/2021. RD also stated residents who have decreased or no appetite, should be evaluated for underlying causes. However, Resident 1 was not evaluated for underlying conditions by the interdisciplinary team (physician, RD, licensed nurses, etc.). RD 1 stated there were no further RD evaluations. On 8/2/2021 at 6:19 p.m., during an interview, DON stated the last laboratory tests for Resident 1 were in 2/2021. DON stated the attending physician would only order laboratory if there was any change of condition. DON stated staff did not inform the attending physician of the resident's change of condition when his oral intake decreased on 4/29/2021.There was no daily calorie count (amount of calorie consumed) or a measurement of Resident 1's fluid intake. Resident 1 was not referred for a swallowing evaluation and was not placed on an individual feeding program. Resident 1's diet was not changed to small and frequent feeding to attempt to increase intake. DON acknowledged there were no individual specific interventions developed or implemented addressing the resident's low oral intake. A review of Resident 1's GACH's History and Physical exam dated 5/7/2021 timed at 4:30 p.m., indicated Resident 1 blood pressure was 82/61 millimeters of mercury (mmHg - normal range below 140/80 and above 90/60). Resident 1 was admitted with altered mental status who presented with low blood pressure and low oxygen level. Resident 1's diagnosis included sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death) and acute encephalopathy (disease in which the functioning of the brain is affected by some agent or condition such as viral infection or toxins in the blood) from infectious process. A review of facility's policy and procedure titled, "Change in a Resident's condition or status" revised on 5/2017, indicated that prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including information prompted by the interact SBAR communication form. The facility failed to ensure Resident 1 maintained acceptable parameters of nutrition and hydration and had adequate food and fluid intake. The facility did not develop and implement interventions to assist Resident 1 with improving oral consumption of food and fluids and did not evaluate possible causal factors for the resident's poor oral intake. As a result, Resident 1's general condition deteriorated due to poor food and fluid intake, and on 5/7/2021, he required transfer to General Acute Care Hospital 1 (GACH 1). Resident 1 was diagnosed with sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death) and acute encephalopathy (disease in which the functioning of the brain is affected by some agent or condition such as viral infection or toxins in the blood) from an infectious process and placed the resident at risk for death. The above violation had a direct or immediate relationship to the health, safety, or security of Resident 1.