§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.
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Observations:
Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to follow physician orders and adequately monitor significant weight changes for three of eight residents reviewed for nutrition (Residents 18, 36 and 37).
Findings include:
Review of facility policy, "Weight and Weight Change Management," last revised date unknown, revealed: "Resident weights will be obtained to provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident. Each resident will be weighed monthly or more frequently as deemed necessary by physician orders, Dietician, or IDT (interdisciplinary team) recommendation. "
Clinical records review revealed Resident 18 was admitted to the facility on April 23, 2024, with diagnosis of Congestive Heart Failure (CHF-A weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs), Chronic Kidney Disease (CKD-Gradual loss of kidney functions which can result to renal failure), and right leg bimalleolar fracture (A serious ankle injury that involves breaks in both the medial and lateral malleolar bones).
A review of Resident 18's physician's order dated April 24, 2025, revealed an order for a daily weight one time a day, ensuring wheelchair weight is subtracted before inputting the weight.
A review of the weight and vitals revealed the following weights: 204 pounds on April 25, 2025, 204.2 pounds on April 26, 2025, 203.4 pounds on April 27, 2025, 204.1 pounds on April 28, 2025, and 204.4 pounds on April 29, 2025, which revealed a stable weight from April 25 until April 29, 2025. On May 3, 2025, the resident's weight was 247.8 pounds. A reweigh was done which also revealed 247 pounds, a 43.4 (21.23%) significant weight gain in four days.
A review of the dietitian's progress notes dated May 5, 2025, revealed the resident with a weight gain of 40 pounds, reweight also showing +40 pounds. The notes also revealed that "RD (registered dietitian) checked wheelchair weight alone and it's 47.4 #. Weight gain x 1 (one) day most likely due to not subtracting wheelchair weight when inputting weights obtained. RD spoke to the nurse for the resident today and emphasized subtraction of wheelchair weight/clarification from CNA (certified nursing assistant) if the subtraction was completed or not before inputting into the system". "Spoke to MD (physician) about weight gain and made aware of weight change most likely r/t (related to) wheelchair weight being included.
An interview with the Dietitian, licensed Employee E3 conducted on May 15, 2025, at 11:30 a.m., confirmed that the significant weight gain was due to the wheelchair not subtracted before inputting the weight into the system. The dietitian reported that the current daily weights (240 + pounds) documented in the weights and vitals were all with a wheelchair.
An interview with an Occupational therapist (A healthcare provider that helps people to improve their daily living tasks and activities), Employee E5 was conducted on May 16, 2025, at 11:00 a.m. Employee E5 reported providing treatment and rehabilitation services for Resident 18. Employee E5 reported that she/he took the resident's weight on May 16, 2025, and it was 244 pounds without a wheelchair.
An interview was conducted with the Director of Nursing on May 16, 2025, at 1:00 p.m. The DON was unable to provide a valid explanation of the 40 + pounds significant weight change in four days.
The facility failed to ensure Resident 18's weight was appropriately monitored and addressed.
Review of Resident 36's face sheet revealed medical diagnoses that include, Progressive Bulbar Palsy (damage to cranial nerves responsible for controlling muscles for speech, swallowing and facial movement), Sever Protein Calorie Malnutrition (insufficient energy, fat protein and nutrients), Amyotrophic Lateral Sclerosis (ALS - loss of muscle control), Acute Respiratory Failure with Hypoxia (lack of oxygen in blood), Dysarthria (speech disorder) and Anarthria (loss of muscle control for speech).
Review of Resident 36's clinical records revealed a care plan dated March 10, 2025, documenting Resident 36 is at nutritional/hydration risk secondary to need for Enteral (nutritional intake via tube) feeding and flushes to maintain nutritional status. Inability to meet established nutritional needs with PO (by mouth) diet, history of prior need for mechanical altered diet with thickened liquids, history of altered lab values, history of inadequate PO intake, and increased risk for clinical changes including weight, skin and lab changes.
Review of Resident 36's physician orders revealed an order dated May 1, 2025, for weekly weights for four weeks with an end date of May 29, 2025. Per the physician orders Resident 36 should have been weighed on May 1, 2025, May 8, 2025, May 15, 2025, and May 22, 2025.
Review of Resident 36's physician orders revealed an order dated April 24, 2025, for NPO (nothing by mouth) diet, NPO texture, NPO consistency.
Further review of Resident 36's physician orders revealed an order dated May 2, 2025, for Enteral Feed four times per day via Bolus Feeding Tube (tube syringe used to provide nutrition). Nutren 2.0 (a nutrition formula), 220cc 4 times per day, every 6 hours, total volume 880cc per 24 hours, providing 1760 kcals, 74grams protein, 609cc free water, per 24 hours.
Review of Resident 36's weights on May 15, 2025, at 12:35 p.m., revealed one weight dated May 1, 2025, at 1:29 p.m. where the resident was recorded as weighing 134.9 lbs.
Further review of Resident 36's weights on May 16, 2025, at 11:15 a.m., revealed a recorded weight dated May 16, 2025, at 10:49 a.m., where the resident was recorded as weighing 137.4 lbs.
Interview with Dietary staff Employee E3 on May 15, 2025, at 12:40 p.m., Employee E3 stated nursing staff is responsible for resident's weights. Employee E3 confirmed Resident 36 was not weighed on May 8, 2025, as ordered. Employee E3 stated he/she had no clarification why Resident 36 was not weighed. Employee E3 confirmed there was no documented explanation as to why Resident 36 was not weighed on May 8, 2025. Employee E3 stated the nursing supervisor was notified of Resident 36's missing weight the following day, May 9, 2025. Employee E3 confirmed Resident 36's next scheduled weighing was May 15, 2025.
Interview with the DON on May 16, 2025, at 11:30 a.m., when the above was mentioned, the DON confirmed Resident 36's physician orders for weekly weights were not followed.
Review of Resident 37's diagnosis list revealed diagnoses but not limited to dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability), anxiety disorder (feelings of persistent anxiety), muscle weakness and depression.
Review of Resident 37's physician orders revealed an order dated May 7, 2025, for weekly weight for four weeks with an end date of June 4, 2025.
Review of Resident 37's clinical record revealed that weights were obtained as follows: April 30, 2025 - 113.2 pounds and May 14, 2025 - 101.0 pounds. Revealed a significant weight loss of 12.2 pounds.
Further review of Resident 37's clinical record failed to reveal that any weights were obtained on May 7, 2025.
The above-mentioned information was conveyed to the Director of Nursing on May 16, 2025, at approximately 1:00pm.
28 Pa. Code 211.5(f) Clinical Records
28 Pa. Code 211.12(d)(1)(5) Nursing Services
28 Pa Code: 211.10(c) Resident care policies
| | Plan of Correction - To be completed: 06/24/2025
1. Resident 18 had no adverse effect. Resident 36 and 37 are discharged from the facility.
2. Active residents with physician ordered daily or weekly weights in the last 7 days will be reviewed to ensure that weights are appropriately monitored and addressed.
3. The Regional Dietician/designee will educate the Dietician on ensuring weights are appropriately monitored and addressed. The DON/designee will educate all nursing staff to ensure weights are obtained per physician orders.
4. Review of medical record related to physician ordered daily or weekly weights will be conducted by Dietician /designee to ensure that weights are appropriately monitored and addressed. Audits will be done weekly x 4 then monthly x2 then quarterly or until compliance is achieved. Findings will be reported to QAPI committee for follow up and recommendations as needed.
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