Health inspection·January 12, 2024

42 CFR §483.25 Quality of Care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices, including but not limited to the following: (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. 22 CCR § 72315 - Nursing Service - Patient Care (h) Each patient shall be provided with good nutrition and with necessary fluids for hydration. 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 11/27/2023, 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 60 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 60 was immediately seen by the Registered Dietitian 1 (RD 1) when the resident was identified as having experienced five pounds (lbs.- unit of measure) weight loss on 9/4/2023. RD 1 did not assess Resident 60 until 9/10/2023, six (6) days later. 2. Resident 60’s Pro-Stat (a liquid food supplement that contains extra protein indicated for increased protein needs related to malnutrition and promotes weight stabilization) recommendation by RD 1 on 9/10/2023, was carried out and implemented. The Pro-Stat was not started until 9/18/2023, eight (8) days later. 3. Resident 60’s enteral feeding (providing nutrition that is delivered through a tube placed into the stomach) recommendation on 9/15/2023, by RD 2 was carried out and implemented. The recommendations were not started until 13 days later. On 9/15/2023, RD 2 recommended to change Resident 60’s feeding formula and gastrostomy tube (G-tube – a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration) feeding rate from Isosource 1.5 (a type of feeding formula [nutrition that is delivered through a tube placed in the stomach] dense in calories and protein so that it supplies more of what the body needs in each serving, making it suitable for those with limited fluid tolerance) at 50 milliliters (ml – unit of measure) per hour (hr. – unit of time) to Isosource High Nitrogen (Isosource HN – a high protein feeding formula providing 1.2 calories per ml and 54 grams [gm – unit of measure] of protein per 1000 ml) 70 ml/hr. to meet Resident 60’s daily nutritional intake and prevent further weight loss. 4. The facility obtained a Complete Metabolic Panel (CMP – a blood test that indicate how the body is functioning including an indication of a resident’s nutritional status) for Resident 60 as ordered by the physician on 10/9/2023. As a result, Resident 60 experienced severe weight loss of 20 lbs., (equivalent of 16% of the resident’s body weight) from 8/31/2023 to 9/25/2023, which placed Resident 60 at risk for further weight loss and medical complications related to inadequate nutrition. A review of Resident 60's Admission Record indicated the facility admitted the resident on 8/30/2023 and readmitted on 10/30/2023 with diagnoses that included respiratory failure (a serious condition that makes it difficult to breathe on your own), diabetes mellitus (a health condition in which the amount of sugar in the blood is elevated), dysphagia (difficulty swallowing), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and presence of a gastrostomy tube (G-Tube- a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid and medication administration). A review of Resident 60' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 11/25/2023, indicated Resident 60 had a severely impaired cognition (ability to think and make decision). The MDS indicated Resident 60 was dependent on staff (helper does all the effort) for eating, toileting, dressing, and personal hygiene. A review of Resident 60’s Weights Summary Log indicated the following: a. 8/31/2023 124 lbs. b. 9/4/2023 119 lbs. c. 9/8/2023 119 lbs. d. 9/11/2023 110 lbs. e. 9/15/2023 110 lbs. f. 9/19/2023 107 lbs. g. 9/22/2023 107 lbs. h. 9/25/2023 104 lbs. i. 9/28/2023 104 lbs. j. 10/2/2023 106 lbs. k. 10/9/2023 106 lbs. l. 10/12/2023 106 lbs. m. 10/16/2023 104 lbs. n. 10/19/2023 104 lbs. o. 10/23/2023 103 lbs. A review of Resident 60’s Mini Nutritional Assessment with an effective date of 9/1/2023, indicated Resident 60 scored five points (Score indicator of zero [0] to seven [7] points mean the resident is malnourished [poor nutrition]). A review of Resident 60’s untitled Care Plan related to enteral feeding, with an initiated date of 9/6/2023, indicated Resident 60 requires enteral feeding and must maintain nutritional status via tube feeding. The Ideal Body Weight (IBW) range for Resident 60 was 131 lbs. to 159 lbs. A review of Resident 60’s Physician’s Order dated 9/7/2023, timed at 12:45 p.m., indicated an order for RD Consult. A review of Resident 60’s Nutritional Assessment Form dated 9/10/2023, timed at 6:44 p.m., completed by RD 1, indicated Resident 60 had a five-pound weight loss in one week. Resident 60’s weight had decreased from 124 lbs. on 8/31/2023 to 119 lbs. on 9/4/2023. The Nutritional Assessment Form further indicated enteral feeding was the sole source of Resident 60’s nutrition. The Nutritional Assessment Form indicated the current (as of 9/10/2023) enteral feeding was not adequate to meet Resident 60’s nutrient needs. The dietary recommendations included to: a. Increase the current enteral feeding to Isosource 1.5 at the rate of 50 cubic centimeters (cc- unit of measure) /hr. for 20 hours to provide the total G-tube feeding volume of 1000 ml and 1500 Kilocalorie (Kcal – unit of energy where 1 kcal equals 1000 calories). During a concurrent interview and record review with the Director of Nursing (DON) on 12/1/2023 at 1:27 p.m., Resident 60’s Nutritional Assessment Form dated 9/10/2023 and Resident 60’s Weights Summary Log from 8/31/2023 to 9/4/2023 were reviewed. The DON stated that it is the facility’s process that once a resident has been identified with weight loss, licensed nurses are to inform the resident’s physician and the facility’s registered dietitian. When the DON was asked why the registered dietitian did not assess Resident 60 for the resident’s five lbs. weight loss in four days (8/31/2023 to 9/4/2023) until 9/10/2023, which was six days from when the facility had first identified the weight loss on 9/4/2023; the DON was unable to respond. A review of Resident 60’s Nutritional Assessment Form, dated 9/10/2023, timed at 6:44 p.m., completed by RD 1 indicated Resident 60 experienced a five-pound weight loss in one week. Resident 60’s weight had decreased from 124 lbs. on 8/31/2023 to 119 lbs. on 9/4/2023. The Nutritional Assessment Form further indicated enteral feeding was the sole source of Resident 60’s nutrition. The Nutritional Assessment Form indicated the current (as of 9/10/2023) enteral feeding was not adequate to meet Resident 60’s nutrient needs. The dietary recommendations included adding Pro-Stat 30 ml BID (twice a day) to provide an additional 30 grams (g – unit of measure), 200 kcals/day to meet nutritional needs. A review of Resident 60’s Physician Orders with an order date of 9/18/2023 and start date of 9/18/2023 indicated to give Pro-Stat oral liquid 30 ml by mouth two times a day for supplement. During a concurrent interview and record review with the DON on 12/1/2023, at 1:30 p.m., Resident 60’s Nutritional Assessment Form dated 9/10/2023 and Resident 60’s Physician Orders for Pro-Stat dated 9/18/2023 were reviewed. When the DON was asked why Resident 60’s Pro-Stat was not ordered and started until 9/18/2023 (eight days after RD 1 had recommend), the DON was unable to respond. A review of Resident 60’s Physician’s Order dated 9/10/2023, with a start date of 9/11/2023, indicated to provide Isosource 1.5 formula at 50 ml/hr. via G-tube for 20 hrs. via G-tube feeding pump (a device that delivers the tube feeding formula with the ability to set the rate [speed] at which the formula is administered to a resident). Start infusion (introduction of liquid) at 2:00 p.m. and to turn off the feeding at 10:00 a.m. or until total volume is completed. A review of Resident 60’s Dietary Nutritional Progress Notes dated 9/15/2023, timed at 1:01 p.m., indicated Resident 60, who is on enteral feeding, was noted with a 14 lbs. weight loss in two weeks. Resident 60’s weight had decreased from 124 lbs. on 8/31/2023 to 110 lbs. on 9/15/2023. RD 2 recommended to change the type of Resident 60’s feeding formula and G-tube feeding rate from Isosource 1.5 at 50 ml/hr. for 20 hrs. to Isosource HN at 70 ml/hr. for 20 hrs. to provide the total G-tube feeding volume of 1400 ml, 1680 kcal and 75.6 gm of protein per day to meet Resident 60’s daily nutritional intake and prevent further weight loss. A review of Resident 60’s Physician’s Order dated 9/28/2023 (13 days after RD 2’s recommendation) indicated to provide Isosource 1.5 formula (feeding formula not changed to recommended Isosource HN) at 70 ml/hr. via G-tube for 20 hrs. via G-tube feeding pump. Start infusion at 12:00 p.m. and to turn off the feeding at 8:00 a.m. or until total volume is completed. During a concurrent interview and record review with the DON on 12/1/2023 at 1:35 p.m., Resident 60’s Dietary Nutritional Progress Notes dated 9/15/2023 and Resident 60’s Physician Orders dated 9/10/2023 and 9/28/2023 were reviewed. When the DON was asked why Resident 60’s feeding formula was not changed from Isosource 1.5 to Isosource HN and the G-tube feeding rate was not increased from 50 ml/hr. to 70 ml/hr. until 9/28/2023 (13 days after RD 2 recommendations), the DON was unable to respond. The DON stated that by implementing dietary recommendations days after they are initially recommended, the facility placed Resident 60 at risk for further weight loss which could then result in a decline in overall health and require hospitalization. A review of Resident 60’s Physician Orders dated 10/9/2023 indicated to obtain a CMP blood test on 10/10/2023. During a concurrent interview and record review with the DON on 12/1/2023 at 1:27 p.m., Resident 60’s Physician Orders for CMP dated 10/9/2023 and Resident 60’s laboratory results for 10/10/2023 were reviewed. There was no CMP result found and there was no documented evidence found that a CMP was obtained for Resident 60 on 10/10/2023. The DON was unable to explain why there was no CMP drawn for Resident 60 on 10/10/2023 as ordered by the physician. A review of the facility’s policy and procedure titled, “Weight Assessment and Intervention” with a revised date of 3/2022, last reviewed by the facility on 10/26/2023 indicated it is the policy of the facility to monitor resident weights for undesirable or unintended weight loss. Any verified weight change of five (5) % or more since the last weight assessment, nursing will immediately notify the dietitian in writing. The policy indicated that the threshold for significant unplanned and undesired weight loss will be based on the following criteria: - One month: five % weight loss is significant; greater than five % is severe. A review of the facility’s policy and procedure titled, “Weight Management,” dated 8/25/2021, last reviewed by the facility on 10/26/2023, indicated in the event of a patterned or significant, unplanned weight loss of at least two (2) % in a week (or three lbs. weight loss), five (5) % in 30 days (or five lbs. weight loss, a resident’s attending physician and dietetics professional will be notified by licensed nursing staff. The dietetics professional will assess the resident, document the assessment, and make recommendations in the resident’s medical record. Request laboratory work if necessary. The facility failed to ensure Resident 60 was provided with good nutrition to maintain acceptable parameters of nutritional status and did not experience unplanned severe weight loss, as indicated in the facility’s policies, by not ensuring: 1. Resident 60 was immediately seen by RD 1 when the resident was identified as having experienced 5 lbs. weight loss on 9/4/2023. RD 1 did not assess Resident 60 until 9/10/2023, six (6) days later. 2. Resident 60’s Pro-Stat recommendation by RD 1 on 9/10/2023 was carried out and implemented. The Pro-Stat was not started until 9/18/2023, eight (8) days later. 3. Resident 60’s enteral feeding recommendation on 9/15/2023, by RD 2 was carried out and implemented. The recommendations were not started until 13 days later. On 9/15/2023, RD 2 recommended to change Resident 60’s feeding formula and G-tube feeding rate from Isosource 1.5 at 50 ml/hr. to Isosource HN to run at 70 ml/hr. to meet Resident 60’s daily nutritional intake and prevent further weight loss. 4. The facility obtained a CMP for Resident 60 as ordered by the physician on 10/9/2023. As a result, Resident 60 experienced severe weight loss of 20 lbs., (equivalent of 16% of the resident’s body weight) from 8/31/2023 to 9/25/2023, which placed Resident 60 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 Resident 60.