Nursing Investigation Results -

Pennsylvania Department of Health
ATTLEBORO NSG AND REHAB CTR
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
ATTLEBORO NSG AND REHAB CTR
Inspection Results For:

There are  72 surveys for this facility. Please select a date to view the survey results.

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ATTLEBORO NSG AND REHAB CTR - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, and Civil Rights Compliance survey completed on September 13, 2019, it was determined that Attleboro Nursing and Rehab Center was not in compliance with the following requirements of 42 CFR Part 483, subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
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.
Observations:


Based on facility policy, clinical record review and staff interview, it was determined that the facility failed to implement nutritional interventions to ensure that residents maintained stable weight and reassess the weight status for five of 35 sampled residents. (Resident 28, 52, 72, 107, 130)

Findings include:

Review of the facility policy entitled "Weight Assessment and Intervention" dated November 2018, revealed that any weight change of 5% or more since the last assessment was to have a reweigh taken the next day. Additionally once the weight was verified staff was to notify the dietitian.

Clinical record review revealed that Resident 28 had diagnoses that included dementia, hypertension, and diabetes. A Minimum Data Set (MDS) assessment dated July 8, 2019, identified that the resident was cognitively impaired and required some assistance with meals. On March 3, 2019, the resident weighed 244.4 pounds and on April 9, 2019, the resident weighed 219.3 pounds, a loss of 25.1 pounds or greater than five percent. There was no documentation that the a reweigh was completed in accordance with policy and no evidence that the dietician had been notified to assess if the loss was accurate.


Clinical record review revealed that Resident 52 had diagnoses that included Alzheimer's, psychosis, and hypertension. The MDS assessment dated June 13, 2019, identified that the resident was cognitively impaired and had weight loss not prescribed by the physician. On May 27, 2019, the resident weighed 115.2 pounds and on June 4, 2019, the resident weighed 104.2 pounds, a loss of 11 pounds or greater than five percent. On June 13, 2019, the resident weighed 105.5 pounds and on June 14, 2019, the resident weighed 111.0 pounds, a gain of 5.5 pounds or greater than five percent. There was no documentation that the a reweigh was completed in accordance with policy and no evidence that the dietician had been notified to assess if the loss was accurate.


Clinical record review revealed that Resident 72 had diagnoses that included Alzheimer's, hypertension, and gastric reflux. The MDS assessment dated August 7, 2019, identified that the resident was cognitively impaired, and had weight loss not prescribed by the physician. On June 6, 2019, the resident weighed 144.8 pounds and on July 2, 2019, the resident weighed 132.6 pounds, a loss of 12.2 pounds or greater than five percent. There was no documentation that the a reweigh was completed in accordance with policy and no evidence that the dietician had been notified to assess if the loss was accurate.


Clinical record review revealed that Resident 107 had diagnoses that included dysphagia, chronic kidney disease, and depression. The MDS assessment dated August 16, 2019, identified the resident required staff supervision with meals. On June 5, 2019, the resident weighed 162 pounds and on July 3, 2019, the resident weighed 154 pounds, a loss of 8 pounds or greater than five percent. There was no documentation that the a reweigh was completed in accordance with policy and no evidence that the dietician had been notified to assess if the loss was accurate.

Clinical record review revealed that Resident 130 had diagnoses that included chronic kidney disease, diabetes, and malnutrition. The MDS assessment dated August 31, 2019, identified that the resident had weight loss not prescribed by the physician. On July 23, 2019, the resident weighed 96.8 pounds and on August 5, 2019, the resident weighed 87.4 pounds, a loss of 9.4 pounds or greater than five percent. There was no documentation that the a reweigh was completed in accordance with policy and no evidence that the dietician had been notified to assess if the loss was accurate.

In an interview on September 13, 2019, at 10:30 a.m., the Director of Nursing stated that the reweigh had not been completed.

28 Pa. Code 211.12(d)(3) Nursing services








 Plan of Correction - To be completed: 10/21/2019

1. R28, R52, R72, R107, R130 weights are being taken according to policy and interventions are in place according to plan of care.
2. Current residents triggering for significant weight loss/gain are being audited weekdays by dietician/designee and are having re-weights completed according to policy.
3. Staff Development/designee will re-educate nursing staff on completion of accurate and proper weights and re-weights and notification to dietician as it relates to policy. DON/designee will re-educate Dietician on policy and reviewing the weight report for significant weight changes for clinical meeting and again at end of day meeting.
4. DON/designee will complete daily audits of residents triggering for significant weight changes to ensure reweights are completed per policy for 4 weeks, then weekly for 2 months.
5. Results and findings of audits will be reviewed at monthly quality assurance performance improvement meetings for 3 months for further recommendations as needed.


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