Health inspection·September 12, 2024

C.F.R., Tit. 42, §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; and (3) Is offered a therapeutic diet when there is a nutritional problem, and the health care provider orders a therapeutic diet. Cal. Code Reg., Tit. 22, §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: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (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. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. (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. Cal. Code Reg., Tit. 22, §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. (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the patient care policy committee. (c) Each facility shall establish and implement policies and procedures, including but not limited to: (D) Notification of the licensed healthcare practitioner acting within the scope of his or her professional licensure regarding sudden or marked adverse change in a patient's condition. On 7/26/2024, the California Department of Public Health (CDPH) received a complaint regarding Resident 1's weight loss. On 7/26/2024, CDPH conducted an unannounced visit to the facility to investigate the complaint allegations. Upon investigation, CDPH determined the facility failed to prevent Resident 1 from having an unplanned severe weight loss (a weight loss greater than 5 percent [%] in one month or a weight loss greater than 7.5 % in 3 months) of 24.3 pounds [lbs.], which was 18.2 %, in the 40 days from 3/11/2024 to 4/20/2024. The facility failed to ensure: a. Staff identified Resident 1's decrease in oral intake (amount of food and water consumed) from 3/16/2024 to 3/27/2024 (a total of 11 days). b. Nursing staff reported the decrease in Resident 1's oral intake to Resident 1's physician (MD 1) when Resident 1 began refusing meals from 3/16/2024 to 3/31/2024 (MD 1 was notified on 4/1/2024, 16 days later). c. Nursing staff followed the facility's policy and procedure (P&P) titled, "Nutrition (Impaired)/ Unplanned Weight Loss- Clinical Protocol" and immediately notified physician of any abrupt or persistent change from baseline appetite or food intake. d. Staff followed the Registered Dietician's (RD 2) recommendations made on 3/29/2023, which indicated to monitor Resident 1's weight and oral intake. e. Follow Resident 1's care plan titled, "Nutritional Risk; Resident has the potential for altered nutrition" which indicated to notify the physician and RD if Resident 1 refused meals and had a significant weight loss. As a result of these failures, Resident 1 had severe weight loss of 18.2 % in 40 days and required the insertion of a gastrostomy tube ([G-tube]- a flexible tube surgically inserted directly into the stomach to provide nutrition and administer medication) on 5/6/2024, and placed Resident 1 at risk for malnutrition (lack of proper nutrition, caused by not eating enough), dehydration (dangerous loss of body fluid), emaciation (abnormally thin or weak, because of illness or lack of food), and death. A review of Resident 1's Admission Record, indicated Resident 1, an 81-year-old female, originally was admitted to the facility on 1/22/2024 and readmitted on 5/10/2024 with diagnoses including metabolic encephalopathy (damage or disease that affects the brain) type II diabetes mellitus (a condition in which the body fails to metabolize glucose correctly), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily life). A review of Resident 1's Minimum Data Set ([MDS]- a standardized assessment and care screening tool) dated 1/29/2024, indicated Resident 1 had severe impairment in cognitive skills (ability to think, understand, learn, and remember) for daily decision making. The MDS indicated Resident 1 had no episodes of refusing care. The MDS indicated Resident 1 weighed 133 lbs. and did not have any weight loss during the Admission Assessment review period. The MDS indicated Resident 1 did not have a G-tube. A review of Resident 1's Care Plan titled, "Nutritional Risk; Resident has the Potential for Altered Nutrition," initiated on 2/9/2024 indicated Resident 1's goal was to maintain adequate nutritional status as evidenced by stable weight and to maintain weight of 133 lbs. plus or minus five percent. The care plan interventions included to observe the resident for signs and symptoms of malnutrition as evidenced by emaciation, refusing meals, significant weight loss, signs and symptoms of dehydration; to report to physician as needed; and for the RD to reassess as indicated. A review of Resident 1's MDS dated 3/9/2024, indicated Resident 1 was discharged from a short term stay at the GACH on 3/9/2024 due to a right hip fracture (broken bone). The MDS indicated Resident 1 did not have a G-tube and weighed 139 lbs. The MDS indicated Resident 1 did not have any episodes of refusing care and only needed assistance setting up her tray during meals. A review of Resident 1's Weights and Vitals Summary form, indicated the following: 1. On 1/23/2024, Resident 1 weighed 133.0 lbs. 2. On 2/25/2024, 138.8 lbs. 3. On 3/11/2024, 133.8 lbs. 4. On 4/20/2024, 109.5 lbs. A review of Resident 1's Weights and Vitals Summary form indicated Resident 1 had a severe weight loss of 24.3 lbs. from 3/11/2024 to 4/20/2024, a total of 18.2% weight loss in 40 days. There was no documented weight for Resident 1 upon readmission from the GACH on 3/14/2024. A review of Resident 1's Certified Nursing Assistant (CNA) documentation titled, "Documentation Survey Report," section titled, "Amount Eaten" for the month of March 2024, indicated prior to Resident 1's hospitalization on 3/9/2024, Resident 1 was eating between 51-100% for most meals. The "Documentation Survey Report indicated out of 27 opportunities of meal percentages documented. Resident 1 had 17 meals where she ate 76-100%, 5 meals in which she ate 51-75%, 3 meals where she ate 26-50%, 1 meal she ate 0-25%, and Resident 1 refused 1 meal prior to hospitalization. The "Documentation Survey Report section "Amount Eaten," indicated that after Resident 1's readmission to the facility on 3/15/2024, Resident 1 refused 5 meals, consumed 0-50% for 10 meals, and consumed 51-100% for 8 meals out of 23 opportunities of meal percentages documented. A review of Resident 1's Nurses Progress Notes dated from 3/2024 through 4/1/2024, indicated there was no documentation addressing Resident 1's poor oral meal intake or identifying any steps taken in response. A review of Resident 1's Physician's Order Summary Report, dated 3/1/2024 to 7/31/2024, indicated an order was placed 3/19/2024 for Trazodone (depression medication) HCl Oral Tablet 100 milligrams (mg) give 1 tablet at bedtime for depressive disorder manifested by the inability to sleep. An order was placed 4/1/2024 for Health Shake NSA (a nutritional shake) three times a day. An order was placed on 5/3/2024 for Remeron (depression medication) 0.5. mg at bedtime for depressive disorder manifested by poor oral intake. A review of Resident 1's History and Physical (H&P) dated 3/17/2024, MD 1 documented Resident 1 was readmitted from the GACH on 3/14/2024 after right hip hemiarthroplasty (right hip replacement due to fracture). A review of Resident 1's Interdisciplinary Team ([IDT]-team members from different departments working together with a common purpose to set goals and make decisions that ensure the resident received the best care) Conference Summary dated 3/27/2024, indicated Resident 1 was compliant with her treatment and not refusing any treatments. The IDT Conference Summary indicated Resident 1 had no significant weight loss, weighed 133.8 lbs. (weight taken on 3/11/2024, 16 days prior IDT conference) and was not receiving tube feeding. The IDT Conference Summary indicated that according to RD 2's progress note dated 3/27/2024, Resident 1's diet was constant carbohydrate ([CCHO]-a diet with the same amount of carbohydrates every day to maintain good blood sugar), regular texture, thin liquids, with bedtime snacks. RD 2's progress notes also indicated Resident 1's oral intake was variable, and the average oral intake was about 60% during the last seven days and had refused three meals. A review of Resident 1's Nutritional Risk Assessment dated 3/29/2024 completed by RD 2, indicated Resident 1 was readmitted from the GACH on 3/14/2024 and had no significant weight changes at that time. RD 2 recommended to add bedtime snacks and a health shake three times a day due to Resident 1's variable oral intake. The Nutritional Risk Assessment indicated to monitor Resident 1's weight and variable oral intake as needed. A review of Resident 1's H&P dated 3/29/2024, indicated Resident 1 was at the GACH from 3/24/2024 to 3/26/2024 for the right hip dislocation (hip joint out of place), and Resident 1 required a revision (second surgery) of the first right hip surgery. Resident 1 was readmitted from the GACH on 3/26/24 (second readmission) The H&P did not indicate Resident 1 had weight loss. A review of Resident 1's Nurses Progress Note dated 4/20/2024, indicated Resident 1 was monitored for poor oral intake. The note indicated Resident 1 was not eating her breakfast, snacks, lunch, or dinner. The Nurses Progress Note indicated that on 4/18/2024 the physician ordered Megace (a medication used to increase appetite) 20 milligram (mg) one tablet three times a day for appetite stimulation, for three weeks. The note further indicated that on 4/20/24, the physician ordered Boost Nutritional drink (a high calorie nutritional supplement) three times a day. A review of Resident 1's IDT Conference Summary dated 4/22/2024, indicated Resident 1 had a severe weight loss and weighed 109.5 lbs. (weight taken 4/20/2024). The IDT Conference Summary indicated Resident 1 had poor oral intake with a history of refusing meals and preferred to drink liquids. The IDT indicated an appetite stimulant, Megace, was started on 4/19/2024 and Resident 1's family was to visit Resident 1 to bring food from outside and see if the resident's meal preferences could be updated. A review of Resident 1's GACH Physician H&P dated 5/6/2024, indicated Resident 1 was admitted to the GACH for failure to thrive and had a G-tube placement. The H&P indicated the resident was hospitalized because the condition posed a danger to Resident 1's health. A review of Resident 1's MDS dated 5/17/2024, indicated Resident 1 had a significant change in status and was readmitted from the GACH on 5/10/2024. The MDS indicated Resident 1 had moderate impairment in cognitive skills for daily decision making. The MDS indicated Resident 1 had a G-tube and was receiving her nutrition via the G-tube. The MDS indicated Resident 1 was now dependent (staff did all the effort to complete the activity) on staff to complete the following activities: toileting, bathing, dressing, and personal hygiene. During a concurrent observation and interview on 7/29/2024 at 10:20 a.m., in Resident 1's room, Resident 1 was lying in bed with a G-tube connected to the G-tube pump (machine that administers feeding). Resident 1 stated, "they feed me through my naval (belly button)" and pointed towards the G-tube machine. During a concurrent interview and record review on 7/30/2024 at 2:36 p.m., with the Quality Assurance Nurse (QAN), Resident 1's Documentation Survey Report section "Amount Eaten" for 3/2024 was reviewed. The QAN stated the significant change in Resident 1's weight was identified on 4/20/2024 when Resident 1 went from 133.8 lbs. on 3/11/2024 to 109.5 lbs. on 4/20/2024. The QAN stated she was unsure how the weight was taken on 3/11/2024 because Resident 1 was in the GACH at that time, and it may have been a data entry error for the date. The QAN stated there was no documented weight upon the resident readmission on 3/14/2024. The QAN stated prior to Resident 1's hospitalization on 3/9/2024, Resident 1 was consistently eating 76-100% and after she was readmitted on 3/14/2024 she was eating less, about 0-50% on most days. The QAN stated there was a decrease in Resident 1's oral intake. The QAN stated a decrease in oral intake should have been reported to the physician right away so interventions could be implemented to prevent weight loss. The QAN stated a change of condition ([COC]- a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional status which without immediate intervention, may result in complications or death) report was not done, and should have been done for the decrease in Resident 1's oral intake so the resident could be closely monitored by the RD and nursing staff. The QAN stated there was no COC report done until 4/20/2024. The QAN stated interventions such as nutritional shakes were placed on 4/1/2024, after the recommendation from RD 2 on 3/29/2024, but a COC was not completed for monitoring. The QAN stated, there was no documentation to indicate the RD (in general), or MD were notified of Resident 1's weight loss or refusal to eat before 3/27/2024. The QAN stated Resident 1 ended up with a G-tube because of her severe weight loss, poor oral intake, and refusal to eat. The QAN stated the facility did not follow Resident 1's care plan to inform the physician when Resident 1 was refusing meals and having poor oral intake. During a concurrent interview and record review on 7/30/2024 at 3:29 p.m., the Director of Nursing (DON) stated per Resident 1's Documentation Survey Report section Amount Eaten dated 3/2024, Resident 1's oral intake was decreased after her readmission from the GACH on 3/14/2024. The DON stated, when Resident 1 began refusing food and consuming less during meals, the physician should have been notified. The DON stated a 24 lbs. weight loss in one month was considered a severe weight loss. The DON stated the potential outcome for residents with poor oral intake or refusin