|§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-
§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.
Based on clinical record review and interviews with staff, it was determined that the facility failed to develop and implement a comprehensive person-centered nutritional care plan that included measurable objectives and timeframes to ensure that one of three resident's maintained acceptable parameters of nutritional status for usual body or desired body weight and electrolyte balance to meet this resident's medical needs (Resident R1).
Review of the clinical record indicated that this resident, R1, had diagnoses of cerebral palsey (impaired muscle coordination (spastic paralysis), hypertension elevated blood pressure), epilepsey(a neurological disorder with abnormal electrical activity in the brain), gastroesophageal disease (acid reflux where the stomach contents rise up into the esophagus) and dysphagia(difficulty swallowing).
Clinical record review revealed that resident R1 was admitted to the facility on July 3, 2018. The resident was admitted to the facility after surgery for closure of a left ischial (curved bone forming the base of each half of the pelvis) pressure sore. The physician's progress note dated July 5, 2018 indicated that Resident R1 had a closure of the left ischium and that it was intact. The physician documented that Resident R1 had a right ischial wound that was necrotic(dead tissue/skin that was black in color) and extended to the muscle fascia (a thin sheath of fibrous tissue), with no abscess (swollen area/tissue with pus) or cellulitis (inflammation of subcutaneous tissue). The physician indicated that Resident R1 also had a right hip pressure ulcer breakdown with no abscess or cellulitis.
Physician progress notes indicated that Resident R1 was admittied to the hopsital on November 2, 2018 and readmitted to the facility on November 16, 2018. The nursing progress note for November 16, 2018 indicated that Resident R1 had a right buttock wound measuring 7.2cm by 7.8cm by .1cm., a right gluteus wound measuring 2.6cm by 1.5cm by .1cm. and right and left heel pressure ulcers.
On December 4, 2018 the physician's progress note indicated that Resident R1 had a stage III pressure ulcer (full thickness skin loss involving damage to, or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia, the ulcer presents clinically as a deep crater.) located on the sacrum. On December 20, 2018 the physician noted that the Resident R1 had a buttock ulcer and also a bloody blister on the left heel.
The dietitian documented weights throughout Resident R1's stay at the facility as 107 pounds on July 13, 2018, 102 pounds on July 19, 2018, 98.6 pounds on August 7, 2018, 107.6 pounds on September 14, 2018 and 111 pounds on December 10, 2018.
The dietitian's progress note dated July 13, 2018 indicated that Resident R1 was ordered a mechanical soft diet . The dietitian indicated that resident was not consuming enough foods by mouth to support/maintain nutritional status. The dietitian indicated that Resident R1 had to rely on an enteral feeding formula for nutrition and hydration needs.
Throughout Resident R1's stay at the facility (July through December 2018), there was no nutritional care planning established and available for review that contained measurable goals, related to usual body weight, desired body weight, ideal body weight, wound healing goals with blood protein level assessment (transthyretin) or electrolyte monitoring related to nutrition needs and hydration status. It was confirmed during an interview with the dietitian at 10:00 a.m., on January 22, 2019 that there was no frame size assessed for Resident R1. The dietitian also confirmed that measurable weight goals/parameters were not care planned for Resident R1. There was no documented nutritioinal assessments available for review related to Resident R1's usual body weight or ideal body weight, based on Resident R1's recorded height of 60 inches, the presence of ulcers and wounds and hydration needs. Thoughout Resident R1's stay at the facility July to December 2018 this resident was well below 116.6 or 123 pounds. There were no weight parameters established for Resident R1; that is there was no care plan established for weekly weights to assess the residents tolerance and acceptance/absorption of the enteral formula and water flush as ordered by the physician. There were no nutrition related laboratory studies (sodium, potassium, chloride), planned and obtained for July, August or October, 2018. Weights and laboratory assessment for a resident receiving nutritional sustenance through a tube feeding was standard of practice for assessment and monitoring of nutrition needs and hydration status. Interview with the dietitian at 10;00 a.m., on January 22, 2019 confirmed that weekly weights were not available for review for Resident R1. The dietitian also confirmed that there were no laboratory values that were used to evaluate hydration and nutritional status available for review for July, August or October, 2018. According to the Nutrition Care of the Older Adult Manual, Academy of Nutrition and Dietetics, 2016, monitoring is crirical in older adults with enteral feeding tubes, because of diminished compensatory mechanisms. Tube fed persons should have body weight and vital signs monitored daily.
A laboratory study completed on September 26, 2018, Resident R1 was noted with an elevated sodium, chloride and osmolality level. There was no documentation to indicate that the dietitian assessed Resident R1's nutritional needs related to calories, protein and water and the elevated laboratory studies during the month of September, 2018, especially related to the laboratory irregularities cited on September 26, 2018. There was no documented nutritional assessment of Resident R1's tube feeding formula and flush, despite the insufficient fluids or hydration status represented by the resident's laboratory values of elevated sodium, chloride and osmolality which are indices for insuffient nutrient intake and dehydration, according to the Nutrition Care Manual of the Older Adult, Academy of Nutrition and Dietetics, 2016. This lack of assessment was confirmed during an interview with the dietitian at 10:00 a.m., on January 22, 2019.
There were no nutritional related laboratory studies (sodium, chloride, blood urea nitrogen or transthyretin) or dietitian assessments available for review for the month of October, 2018. This lack of nutrition assessment and monitoring of hydration and protein status, was confirmed during an interview with the dietitian on January 22, 2019.
On November 1, 2018 laboratory values were reported for an elevated sodium, chloride and osmolality level. The physician's was notified and sent the resident to the hospital where the resident was diagnosed with aspiration pneumonia and dehydration. The resident returned to the facility on November 16, 2018. On December 21, 2018 Nursing progress notes indicated that this resident was sent to the emergency room by the physician at the family members request.
The facility failed to develop and implement a comprehensive person-centered nutritional care plan that included measurable objectives and timeframes to ensure that one resident maintained acceptable parameters of nutritional status for usual body or desired body weight and electrolyte balance to meet this resident's medical needs (Resident R1).
28 Pa. Code: 211.11(a)(b)(c) Resident care plan
28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services
28 Pa. Code: 211.6(d) Dietary services
28 Pa. Code: (f) Clinical records
| ||Plan of Correction - To be completed: 03/08/2019|
The resident that was found to have a deficient practice has been discharged. No other residents have been affected.
All residents with feeding tubes will be audited to ensure the care plan are individualized and comprehensive with measurable nutrition and hydration parameters
Dietician will be educated on development a comprehensive and individualized to ensure measureable nutritional goals are in place with regards to body weight and electrolyte balance for residents with enteral feeding
Resident with enteral feeding will have a comprehensive nutritional assessment at least quarterly and update care plan to reflect nutrition and hydration changes
Dietician and/or designee will audit enteral care plans weekly x 4 weeks, then monthly x 3, results to be reported at QAPI. Governing body to determine need fro ongoing audits.