Other·August 20, 2021

§483.25(g)(4)-(5) Enteral Nutrition §483.25(g)(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident’s clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and §483.25(g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. Title 22- 72523 (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. 72315 (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. (h) Each patient shall be provided with good nutrition and with necessary fluids for hydration On 6/8/2021, an unannounced visit was made to the facility to conduct a complaint investigation regarding quality of care and treatment. The facility failed to ensure Resident 1 who had a behavior of pulling out gastrostomy tube (G-Tube, an opening into the stomach from the abdominal wall, made surgically for the introduction of food and/or medication), was provided necessary measures to prevent G-Tube complications by ensuring: a. Resident 1’s care plan to monitor attempts of tugging and pulling of G-Tube was implemented. b. Resident 1’s attending physician was notified regarding behaviors of tugging and pulling out G-Tube to prevent the resident from continually pulling out the G-Tube. c. The facility's Policy and Procedure on gastrostomy tube to use a Flexi-Trak (an anchoring device used to anchor tubes and catheters to the skin) to anchor the G-Tube was implemented to prevent Resident 1 from tugging and pulling out the G-Tube. As a result, Resident 1 pulled out her gastrostomy tube and was transferred to a General Acute Care Hospital (GACH) on 5/23/2021 for gastrostomy tube reinsertion. On 5/24/2021, 11 hours after the G-Tube reinsertion, Resident 1 was transferred back to GACH for another G-Tube reinsertion. This placed Resident 1 at risk for G Tube associated infection and complications. A review of Resident 1's Admission Record indicated the resident was admitted to the facility on 5/11/2021 with diagnoses that included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following a large stroke (occurs when blood supply to a part of the brain is interrupted or reduced) and diabetes mellitus (long term condition affecting the body's ability to regulate blood sugar level). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care planning tool), dated 5/24/2021, indicated the resident had severely impaired cognition (ability to understand). The MDS indicated Resident 1 required extensive assistance with bed mobility, transfer, on and off unit locomotion (the ability to move from one place to another), dressing, toileting, and personal hygiene. The MDS indicated Resident 1 was totally dependent on staff with eating. A review of Resident 1's GACH record titled "Orders" dated 5/7/21 to 5/11/21 indicated the resident had history of agitation, combative behavior, and attempts to remove vital lines or tubes and mitten was applied to right arm from 5/7/21 to 5/11/21. A review of Resident 1's Care Plan dated 5/11/2021, indicated the resident had episodes of attempting to pull out G-tube and the goal was for the resident to remain free from discomfort, complications or signs and symptoms related to gastro-intestinal alterations. The care plan interventions included monitoring for attempt of tugging/pulling on G-Tube. A review of Resident 1's Change of Condition dated 5/23/2021, indicated the resident pulled out her G-Tube and the resident was transferred to GACH for tube replacement. A review of Resident 1's Nursing Home to Hospital Transfer Form dated 5/23/2021, indicated G-Tube replacement as the reason for transfer. A review of Resident 1's Progress Notes dated 5/23/2021, timed at 6:50 p.m., indicated the resident returned back to the facility from GACH after a Percutaneous Endoscopic Gastrostomy (PEG - a procedure to place a feeding tube) tube reinsertion. A review of Resident 1's Progress Notes dated 5/24/2021, at 6:00 a.m., indicated Resident 1 pulled out her G-Tube again at 2:30 a.m. the next morning and was transferred back to GACH at 5:45 a.m., 11 hours after the G-Tube was re-inserted. During an interview on 6/8/2021 at 2:12 p.m., Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 was transferred to GACH on 5/23/2021 because she pulled out her G-Tube. LVN 1 stated Resident 1 came back to the facility the same day with a new G-Tube in placed. LVN 1 stated Resident 1 was transferred to the hospital on 5/24/2021 after she pulled out her G-Tube the second time at the facility. LVN 1 stated Resident 1 had a history of attempts of pulling tubes from the hospital. During an interview on 6/8/2021 at 3:58 p.m., the Director of Nursing (DON) stated Resident 1 had a history of attempts of pulling tubes from the hospital. DON stated interventions on residents with behavior of pulling out tubes included monitoring for tugging and pulling by visual check or hourly rounding, informing the physician of the residents' behavior, requesting for additional order on how to secure the G-Tube, offer medications to calm down the resident and a sitter if needed. The DON stated repeated pulling out of the G-Tube put the residents at risk for infection (caused by germs that enter the body, multiply, and cause harm or illness), trauma (emotional response to a highly stressful event) and it will disrupt the nutrition and medication of the resident. During a telephone interview on 7/15/2021 at 8:15 a.m., Certified Nursing Assistant 1 (CNA1) stated she saw Resident 1 on 5/24/2021 at around 2:00 a.m., awake, moving a lot in bed and trying to pull her G-Tube. CNA 1 stated she informed the charge nurse of the residents' behavior. CNA 1 stated the charge nurse said, "to keep an eye on her.” During a telephone interview on 7/15/2021 at 8:43 a.m., Licensed Vocational Nurse 2 (LVN 2) stated Resident 1 came back to the facility on 5/23/2021 after a G-Tube reinsertion. LVN 2 stated she notified the attending physician of the resident's return and orders were resumed, including continuous G-Tube feeding of Osmolite 1.2 at 20 cubic centimeters (cc- unit of measurement) per hour for 20 hours in 24 hours. LVN 2 stated she did not inform the attending physician regarding Resident 1's behavior of pulling out G-Tube. During a telephone interview on 7/15/5021 at 8:50 a.m., LVN 3 stated Resident 1 was more alert, moving a lot and was more active when the resident returned from the hospital on 5/23/2021. LVN 3 stated Resident 1's family requested if the resident could have an abdominal binder to keep the G-Tube in place. LVN 3 stated she obtained a consent to apply an abdominal binder from the family member. LVN 3 stated she did not call the attending physician to obtain an order for the abdominal binder because it was late at night. LVN 3 stated she did not notice if Resident 1 had a Flexi-Trak (device used to anchor G-Tube to the skin to prevent the resident from tugging and pulling the G-Tube) in place. LVN 3 stated the G-Tube was important because it is a life sustaining device and pulling out can hurt the resident and can cause infection. During an interview on 7/16/2021 at 12:58 p.m., CNA 2 stated charge nurses and CNAs alternate in monitoring the residents every two hours. CNA 2 stated she documents residents monitoring of behavior by putting comments in the intervention and task in the resident's activities of daily living (ADLs). A review of Resident 1's Activities of Daily Living Form for the month of May 2021 did not indicate any behavior symptoms recorded for the following days: 5/12/21, 5/13/21, 5/15/21, 5/17/21, 5/18/21, 5/19/21, 5/21/21, 5/22/21 and 5/23/21. During an interview on 7/16/2021 at 1:10 p.m., LVN 4 stated Flexi-Trak is used to anchor G-tube to the skin to prevent residents from tugging and pulling the skin. LVN 4 stated monitoring for tugging and pulling will be documented in the progress notes During an interview and concurrent record review on 7/16/2021 at 1:39 p.m., the DON stated Flexi-Trak was not used on Resident 1. The DON stated the attending physician was not notified of Resident 1's behavior of tugging and pulling "out" the G-tube. The DON stated she is unable to determine if nurses and CNAs were monitoring, making rounds, and doing visual checks on the residents if it was not documented in the daily skilled notes, progress notes, or task in the ADLs. A review of Resident 1's Daily Skilled Notes from 5/12/2021 to 5/22/2021, indicated no documented evidence monitoring of resident's behavior of tugging and pulling out G-Tube was identified. A review of Resident 1's Progress Notes from 5/11/2021 to 5/22/2021, indicated no documented evidence of the resident making attempts of tugging and pulling out G-Tube. A review of Resident 1's GACH Discharge Summary dated 5/30/21 indicated the resident was re-evaluated by Surgery Team. The resident was not a candidate for surgical intervention and Peg Tube replacement due to her cognitive impairment. Resident 1 was discharged home on 5/29/21 on Hospice Care (medical service designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life). A review of the facility's undated Policy and Procedure titled, "Behavior Management", indicated the facility will create, monitor, and update as appropriate, a behavior management plan for each resident who displays behaviors. The Nursing Department will create the behavior management plan for each resident as appropriate. The Licensed Nurse will monitor and update the plan as necessary. The IDT will ensure resident behaviors are assessed in a timely manner and a plan is developed which will implement the least restrictive intervention(s) to address the behavior. In addition, documentation of the effectiveness of the intervention(s) will occur. A review of the facility's undated Policy and Procedure titled, "Licensed Staff Rounds", indicated the facility will ensure the safety and comfort of the resident and to assist in continuity of care and to identify potential change in condition. Residents will be checked by the nursing staff a minimum of every two (2) hours. Observe resident for privacy, dignity, and safety. Note positioning, proper placement of Foley, IV's and feeding tube, restraint application & call lights are within resident's reach. A review of the facility's Policy and Procedure titled, "Gastrostomy Tube", revised 2/8/2020, indicated all stoma sites will be cleaned with NS, pat dry with a clean 4 x 4, apply protective ointment if indicated, apply sterile dressing. Flexi-Trak (optional) anchoring device may be used to anchor G-tube to prevent tugging effect. The facility failed to ensure Resident 1 who had a behavior of pulling out gastrostomy tube (G-Tube, an opening into the stomach from the abdominal wall, made surgically for the introduction of food and/or medication), was provided necessary measures to prevent G-Tube complications by ensuring: a. Resident 1’s care plan to monitor attempts of tugging and pulling of G-Tube was implemented. b. Resident 1’s attending physician was notified regarding behaviors of tugging and pulling out G-Tube to prevent the resident from continually pulling out the G-Tube. c. The facility's Policy and Procedure on gastrostomy tube to use a Flexi-Trak (an anchoring device used to anchor tubes and catheters to the skin) to anchor the G-Tube was implemented to prevent Resident 1 from tugging and pulling out the G-Tube. As a result, Resident 1 pulled out her gastrostomy tube and was transferred to a General Acute Care Hospital (GACH) on 5/23/2021 for gastrostomy tube reinsertion. On 5/24/2021, 11 hours after the G-Tube reinsertion, Resident 1 was transferred back to GACH for another G-Tube reinsertion. This placed Resident 1 at risk for G Tube associated infection and complications. This violation had a direct or immediate relationship to the health, safety, or security of Resident 1. .