Other·February 7, 2023

F692 42 CFR § 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.

F684 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 residents' choices. 22 CCR § 72315 Nursing Service-Patient Care. (g) Each patient requiring help in eating shall be provided with assistance when served and shall be provided with training or adaptive equipment in accordance with identified needs, based upon patient assessment, to encourage independence in eating. 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: (3)Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (D) A change in weight of five pounds or more within a 30-day period unless a different stipulation has been stated in writing by the patient’s licensed healthcare practitioner acting within the scope of his or her professional licensure. 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. The California Department of Public Health (Department) received a complaint on 11/30/2022, indicating a resident (Resident 1) was found unresponsive. The complaint alleges the facility waited 30 minutes before calling the ambulance. Resident 1 was transferred to a general acute care hospital (GACH) where she expired. The complaint alleges the complainant was informed Resident 1 was dehydrated from not drinking or eating but the facility did not inform her the resident was not doing well. On 12/1/2022, an unannounced complaint investigation was conducted at the facility. The facility failed to prevent weight loss and dehydration (dangerous loss of body fluid caused by illness, sweating, or inadequate intake) as per the resident’s plan of care and the facility’s policy and procedure (P&P) for Resident 1 by failing to: 1. Ensure Resident 1’s intake and output status and gradual weight loss was assessed and addressed by the licensed staff and Registered Dietician (RD, health professional who has special training in diet and nutrition) from 8/20/2022 to 9/23/2022 and implement interventions such as honoring the resident’s food preferences (likes/dislikes) when Resident 1 began to refuse to eat. 2. Ensure the RD was notified of Resident 1’s continued decreased oral intake and implement resident-specific interventions to prevent further weight loss from 9/13/2022 to 11/23/2022, a total of 39 pounds (lbs). 3. Ensure a resident-centered care plan was updated further and implemented after an initial revision on 10/6/2022, to address and manage Resident 1’s continued decline in fluid and food intake and significant weight change. 4. Notify Resident 1’s physician of continued decrease in appetite and refusal to eat from 10/10/2022 to 11/23/2022. As a result, Resident 1 had insidious (gradual unintended weight loss over time) weight loss leading to severe weight loss of 6.7 percent (%) in one month (September to October) due to lack of continuous monitoring and interventions. The resident lost a total of 39 lbs from 9/13/2022 to 11/23/2022. The facility last weighed Resident 1 on 11/1/2022 with a weight of 180 lbs (13 lb weight loss). On 11/23/2022, Resident 1 was transferred to a GACH and expired. The GACH noted Resident 1’s weight of 154 lbs (39 lb weight loss from 9/13/2022 to 11/23/2022) on 11/23/2022. During a review of Resident 1’s Admission Record, the admission record indicated Resident 1, was a 61 year-old female, who was admitted to the facility on 8/20/2022 with diagnoses that included hemiplegia (paralysis [inability to move] of one side of the body) and hemiparesis (weakness or the inability to move on one side of the body) following a cerebral vascular accident (CVA, often referred to as stroke or a brain attack in which there is a disruption in the flow of blood to cells in the brain), dysphagia (difficulty in swallowing food or liquid), muscle weakness (a decrease in strength in one or more muscles), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), Parkinson’s disease (a degenerative condition of the brain associated with motor symptoms [slow movement, tremor, rigidity and imbalance]), and anxiety disorder (a mental health condition with frequently intense, excessive and persistent worry and fear about everyday situations). During a review Resident 1’s Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 8/26/2022, the MDS indicated Resident 1’s cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired. The MDS indicated Resident 1 required extensive assistance from staff with bed mobility and dressing, supervision for eating, and was totally dependent on staff with toileting, personal hygiene, and bathing. The MDS indicated Resident 1 had no weight loss of 5 percent or more in the last month or loss of 10 percent or more in the last 6 months. During a review of Resident 1’s History and Physical (H&P), dated 9/17/2022, the H&P indicated Resident 1 had the capacity to understand and make decisions. The H&P indicated Resident 1 was admitted for 24-hour nursing care. The H&P indicated Resident 1’s weight was stable. A review of Resident 1’s Weights and Vitals Summary, dated from 8/23/2022 to 11/1/2022, indicated the following: On 8/23/2022 - 191 pounds (lbs) (2 days after admission) On 8/29/2022 - 193 lbs On 9/5/2022 - 193 lbs On 9/13/2022 - 193 lbs On 9/19/2022 - 189 lbs On 9/26/2022 - 186 lbs On 10/5/2022 - 184 lbs On 10/10/2022 - 180 lbs On 10/17/2022 - 180 lbs On 10/24/2022 - 181 lbs On 10/31/2022 - 180 lbs On 11/1/2022 - 180 lbs (last recorded weight at the facility). During a review of Resident 1’s Physician Order Summary Report, the order summary report indicated the following orders: 1. 8/20/2022 - weekly weights for 4 weeks was ordered. 2. 8/20/2022 - no added salt diet, chopped texture, thin liquids consistency for breakfast, lunch, and dinner. 3. 8/20/2022 - monitor for side effects of Ativan (medication used to treat anxiety) use; drowsiness, dizziness, loss of coordination, headache, nausea, blurred vision, constipation, heartburn, and change of appetite. 4. 10/1/2022 - fortified diet (foods that have nutrients added that the food would not naturally contain), mechanical soft (a diet designed for people who have trouble chewing and swallowing), chopped texture, thin liquids consistency for breakfast, lunch, and dinner. 5. 10/4/2022 Megestrol Acetate Suspension (Megace, used to help raise feelings of hunger) 400 milligrams (mg, a unit of mass or weight), by mouth two times a day for poor appetite. During a review of Resident 1’s Nutrition (PO [by mouth] Intake) records, the records indicated from August to November 2022, the forms were incomplete. A review of Resident 1’s dietary records indicated alternative foods, snacks, or supplements were not consistently offered or provided to Resident 1 when the resident ate only small amounts from meals or refused meals altogether. During a review of Resident 1’s Weights and Vitals Summary, effective date range 8/20/2022 to 11/23/2022, the summary indicated Resident 1 lost 13 lbs, 6.7 percent (%) of her body weight within 27 days. Resident 1’s weight went from 193 lbs on 9/13/2022 to 180 lbs on 10/10/2022. During a record review of Resident 1’s Nutritional Risk Assessment (Admission/ Annual), dated 9/2/2022, the assessment indicated Resident 1’s diagnoses of depression and anxiety placed the resident at high risk for nutritional problems. The assessment indicated Resident 1’s weight gain or loss was to not exceed more than 4% of her current body weight of 193 lbs. The assessment indicated Resident 1’s PO intake was consistently meeting greater than 75 % of needs and was on monitoring and evaluation of weight and oral intake changes. The assessment indicated the plan for Resident 1 was weight maintenance and not weight loss. The assessment also indicated for Resident 1’s food preferences (likes/dislikes), to refer to the “Dietary Screening Report” which identifies a resident’s food preferences. A review of Resident 1’s clinical records indicated there was no Dietary Screening Report completed. During a review of Resident 1’s care plan titled, “Hydration Risk: At risk for Fluid Volume deficit related to (R/T) advanced age,” date initiated 9/13/2022, the care plan indicated Resident 1 would be well hydrated as evidenced by no weight loss, moist mucous membranes, good skin turgor (ability of skin to change shape and return to normal) and laboratory (labs) results within normal limits. The staff’s interventions indicated to monitor Resident 1’s labs, weights, promote good nutrition, and promote good PO intake. During a review of Resident 1’s care plan titled, “Noted Recent Weight Change of nine (9) lbs. Weight Loss in a Week,” initiated 9/19/2022 and revised on 10/6/2022, the care plan indicated Resident 1 would eat at least 50 percent of meals and drink adequate fluids. The staff’s interventions included to monitor and record Resident 1’s weight, refer to the interdisciplinary team (IDT, group of different disciplines working together towards a common goal for a resident) for review and additional interventions, monitor lab work and provide supplements as ordered. During a review of Resident 1’s “Lab Results Report,” dated 9/30/2022, the report indicated all lab results, including Albumin ( a blood protein that delivers nutrients throughout the body) were within normal range. During a review of Resident 1’s Nutrition/Dietary Note dated 10/14/2022, the note indicated Resident 1 experienced a significant undesired weight loss of four (4) lbs in one week. The note indicated on 10/3/2022, Resident 1’s weight was 184 lbs and on 10/10/2022, the weight dropped to 180 lbs. The record indicated Resident 1’s weight loss was related to variable PO intake, urinary tract infection (UTI, bladder infection), and psychotropic medications (medications used to treat mental disorders), which may decrease appetite. The record further indicated Resident 1 was receiving Megace to stimulate appetite and would be monitored for improvement in PO intake and weight changes with a re-evaluation in 7 days. A review of Resident 1’s medical records indicated there was no re-evaluation addressing the resident’s PO intake and weight changes after 7 days. A review of Resident 1’s Order Summary Report dated 12/1/2023, indicated there was a physician’s order dated 10/16/2023, to administer multivitamin-minerals tablet, by mouth one time a day. During a review of Resident 1’s Nutrition note, and Nurses Progress note dated 11/22/2022, the notes indicated Resident 1 ate 0-25 % for breakfast and lunch. There was no documentation for dinner and no documented evidence a change of condition (COC) was initiated on this date regarding Resident 1’s poor PO intake. During a review of Resident 1’s Situation, Background, Assessment, and Recommendation (SBAR, communication form) dated 11/23/2022, the SBAR indicated on 11/23/2022 at 3:15 p.m., staff found Resident 1 unresponsive with no pulse, and no breathing noted. Staff called 911 and paramedics transferred Resident 1 to a general acute care hospital (GACH). During a review of Resident 1’s GACH’s Emergency Department (ED) Note, dated 11/23/2022, the note indicated Resident 1 was transferred via emergency medical services (EMS) for unresponsiveness and cardiac arrest (when the heart stops beating suddenly). A review of Resident 1’s GACH ED laboratory results dated 11/23/2022 indicated the following laboratory results: 1. Blood Urea Nitrogen (BUN, test to determine kidney function): elevated at a level of 49 milligrams (mg, unit of measurement) per (/) deciliter (dL, unit of measurement). Normal Reference Range (NRR) 7-20 mg/dL. 2. Creatinine (test to determine kidney function): elevated at a level of 5.3 mg/dL. NRR 0.50-1.30 mg/dL. 3. Sodium (electrolyte which plays a critical role in helping the cells maintain the right balance of fluid and used to help cells absorb nutrients in the body): elevated at a critically high level of 170 millimoles per liter (mmol/L). NRR 137-145 mmol/L. 4. Potassium (critical to the heart function, too much or too little can cause serious heart problems): elevated at a critically high level of 6.4 mmol/L. NRR 3.5-5.1 mmol/L. 5. Total Protein (test measures the amount of protein in the blood, which are important for the health and growth of the body's cells and tissues): low level of 3.1 grams (g)/dL. NRR 6.3-8.2 g/dL. 6. Albumin: low level of 1.4 g/dL. NRR 3.0-5.0 g/dL. [NRR] 3.0 to 5.0 grams per deciliter [(g/dL]). During a review of Resident 1’s GACH ED Note dated 11/23/2022, the note indicated per the EMS report, Resident 1 received 36 minutes of cardiopulmonary resuscitation (CPR, emergency life-saving procedure performed when the heart stops beating) at bedside at the facility followed by 10 minutes of CPR in route to the GACH. The note indicated at presentation to the ED, Resident 1 was apneic (breathing repeatedly stops and starts) and pulseless with CPR in progress. CPR was continued for approximately 35 minutes in the ED. Resident 1 was intubated (placement of a flexible plastic tube into the trachea to maintain an open airway) and regained perfusing pulse for approximately 10 minutes. CPR was re-initiated and after 10 minutes, Resident 1 was pulseless and without respiratory effort nor heart sounds. Resident 1 was declared deceased on 11/23/2022 at 5 p.m. According to the ED records, Resident 1’s weight upon arrival to the GACH was 70 kilograms (154 lbs). During a telephone interview with RD 1 on 12/29/2022 at 2:06 p.m., RD 1 stated there were no follow up notes after 10/14/2022, because Resident 1’s weight was stable at 180 lbs. RD 1 stated she did not look into Resident 1’s poor PO intake because the resident’s weight was okay. RD 1 stated there were no nutrition labs recommended to Resident 1’s physician for October and November 2022 because September 2022’s lab results were “good” despite the resident’s poor PO intake. RD 1 stated she did not make additional recommendations to address Resident 1’s continued poor PO intake. During an interview with Certified Nursing Assistant (CNA) 2 on 1/6/2023 at 1:05 p.m., CNA 2 stated Resident 1 was confused, needed help with eating, and was unable to eat on her own. During an interview with RD 1 on 1/6/2023 at 1:07 p.m., RD 1 stated she was not notified Resident 1 had poor PO intake. RD 1 confirmed snacks were not offered. RD 1 stated if she knew Resident 1 was not eating well, she would have recommended to order supplements to prevent losing more weight. RD 1 confirmed Resident 1 had three or more episodes of poor meal intake in a two-day period. RD 1 was unable to provide documentation of Resident 1’s calorie count and measurement o