§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 select facility policy and clinical records, and staff interview it was determined the facility failed to timely identify significant weight loss and monitor resident's weights consistently and accurately to timely identify changes in nutritional parameters and timely implement nutritional interventions for two of 24 residents sampled. (Residents 72 and 27)
Findings include:
Review of the facility Weight Monitoring Policy last reviewed March 2024 indicated the facility will ensure all residents maintain acceptable parameters of nutritional status. Information from the nutritional status and dietary standards are used to develop an individualized care plan. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: 1 month- 5% weight loss is significant; 3 months- 7.5% weight loss is significant; 6 months- 10% weight loss is significant.
A review of Resident 72's clinical record revealed admission to the facility on September 21, 2022, with diagnoses to include dementia (the loss of thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities).
A review of the resident's weights noted the following:
September 3, 2024, 164.1 Lbs.
October 8, 2024, 173.5 Lbs.
It was noted the resident refused a weight in November of 2024.
December 5, 3024- 155.1 pounds indicating a 17.4-pound weight loss or 10% loss of body weight within sixty days.
Review of a dietary note dated December 13, 2024 (eight days after the weight loss occurred), confirmed the weight loss and recommended discontinuing health shakes, adding Boost twice daily, and initiating weekly weight monitoring.
Further review of the clinical record revealed no documented evidence that weekly weights were obtained as ordered. Resident 72's care plan was reviewed, and her nutritional care plan was not updated after the significant weight loss was noted on December 13, 2024, as directed in the facility's policy and as noted in the Registered Dietician's dietary note dated December 13, 2024.
Interview with the Registered Dietitian (RD) on February 27, 2025, at approximately 11:30 AM confirmed the resident's weekly weights were not obtained following the weight loss on December 5, 2024, and failed to provide documented evidence the resident's care plan was updated to address the residents weight loss.
A review of a facility policy entitled "Weight Assessment and Intervention" that was last reviewed by the facility March 2024, indicated that the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss. The nursing staff will measure resident's weights upon admission times two, then weekly for 4-weeks, then monthly thereafter if no further weight concerns. Any weight change of 5% or more since the last weight assessment will be retaken for confirmation. The dietitian will review the weight records. Negative trends will be evaluated by the treatment team whether the criteria for significant weight change have been met.
Further review of a facility policy "Nutritional Assessment", last reviewed by the facility March 2024, indicated as a part of the comprehensive assessment, a nutritional assessment, included current nutritional status and risk factors for impaired nutrition shall be conducted for each resident. The dietitian, in conjunction with the nursing staff and health care practitioners, will conduct a nutrition assessment for each resident upon admission and as indicated by a change in condition that places the resident at risk for impaired nutrition.
A review of Resident 27's clinical record revealed the resident was initially admitted to the facility on September 26, 2024, and most recently readmitted from the hospital to the facility on January 29, 2025, with diagnoses that included congestive heart failure (CHF a progressive heart disease that affects pumping action of the heart muscles and causes fatigue, fluid accumulation, and shortness of breath), chronic kidney disease (involves a gradual loss of kidney function and impacts the kidneys ability to filter wastes and remove excess fluids from the blood, which are then removed in urine. Advanced chronic kidney disease can cause dangerous levels of fluid, electrolytes and wastes to build up in your body), hemodialysis (a treatment to filter wastes and water from blood and helps control blood pressure and balance important minerals, such as potassium, sodium, and calcium, in blood), Clostridium difficile (C. diff a type of bacteria that can cause colitis, a serious inflammation of the colon and infections from C. diff often start after taking antibiotics and can sometimes be life-threatening), and moderate protein calorie malnutrition (an imbalance of nutrients from food and drinks that are needed to keep the body healthy and functioning properly). Additionally, Resident 27 had moderate cognitive impairment with a BIMS score of 9 (brief interview for mental status, a tool to assess the resident's attention, orientation and ability to register and recall new information, a score of 08-12 equates to moderate impaired cognition).
Further review of Resident 27's clinical record revealed that he was hospitalized on January 23, 2025, and readmitted to the facility on January 29, 2025, with diagnosis nontraumatic intracerebral hemorrhage (a type of stroke that causes blood to pool between the brain and skull and prevents oxygen from reaching the brain) and actively being treated for C. Diff.
A review of Resident 27's weight record revealed the following recorded weights:
January 17, 2025, at 5:08 PM, 205.5 - pounds post dialysis
January 29, 2025, at 8:21 PM, 189.2 - pounds with use of a mechanical lift (post hospitalization but not confirmed as per the facility policy)
January 31, 2025, at 7:57 PM, 194.7 - pounds post dialysis
February 1, 2025, at 2:53 PM, 181.1 - pounds with use of a mechanical lift
The RD completed a nutrition progress note for a 5-day MDS (Minimum Data Set assessment-a federally mandated standardized assessment conducted at specific intervals to plan resident care) assessment dated February 3, 2025 (5-days post readmission from the hospital) indicated a diet order for a CHO controlled (carbohydrate controlled diet is a diet that provides consistent amounts of carbohydrates to manage diabetes), NAS (no added salt diet involves restricting sodium intake to less than 4 grams, or 4,000 milligrams per day and is usually prescribed to decrease water retention for people who have high blood pressure), regular texture, thin consistency fluids, with an 1800 mL fluid restriction daily (the limitation of oral fluid intake to a prescribed amount for each 24-hour period. This therapeutic measure is indicated in patients who have edema associated with kidney disease). Additionally, the RD's progress note indicated that Resident 27 had a new Stage 2 pressure ulcer (partial thickness loss of skin without true ulceration) to sacrum as per wound care CRNP (certified registered nurse practitioner) note from January 30, 2025. This progress note documented a significant weight loss and a new Stage 2 sacral pressure ulcer but did not initiate immediate nutritional interventions.
The dietitian recommended providing liquid protein (30 mL daily) for wound healing; however, the intervention was not implemented until February 4, 2025 (six days post-readmission and post-identification of the pressure ulcer) as per a review of the Medication Administration Record (MAR). The facility did not provide documented evidence of a timely comprehensive nutritional assessment related to the weight loss and pressure ulcer.
During an interview with the Registered Dietitian (RD) on February 28, 2025, at 11:00 AM, it was reported a nutrition progress note was completed for Resident 27's 5-Day MDS and that it was within the set ARD (assessment reference date). Additionally, the RD confirmed that the nutrition progress note was not completed until 5-days after Resident 27 returned from the hospital with a significant weight loss of 24.4 lbs. or 11.9% in approximately 2 weeks and a significant loss of 29.2 lbs. or 13.9% in 30 days intervention was not put into place until 6-days post identification of a pressure ulcer.
An interview with the Nursing Home Administrator on February 28, 2025, at 1:00 PM, confirmed the facility failed to timely assess and implement nutritional interventions for Resident 27.
28 Pa Code 211.5(f)(ii)(ix) Medical records
28 Pa Code 211.10 (c) Resident care policies
28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services
| | Plan of Correction - To be completed: 04/23/2025
Please note that the filing of this plan of correction does not constitute any admission to the alleged violations set for in the statement of deficiencies. This plan of correction is being filed as evidence of the facility continues compliance with all applicable laws.
- Care plan has been updated and weight obtained for resident 72. Admissions weights are completed daily X2. Then weekly X4 and Monthly afterwards. and as needed
- Audit residents on weekly weights following a weight loss to assure they are completed .
- Audit resident with significant weight loss to assure that the care plan is updated.
- Facility implemented the wound healing intervention on 2/4 as stated in the 2567 and cannot retroactively do it sooner for resident 27. Comprehensive nutritional assessment completed for resident 27.
- Audit residents with weight loss and pressure ulcers to assure that interventions are in place and a comprehensive nutritional assessment is done timely.
- Educate Dietician, and Nursing staff on timely identify significant weight loss and monitor resident's weights consistently and accurately to timely identify changes in nutritional parameters and timely implement nutritional interventions.
- Monthly audits X3.
- Results will be brought to QAPI.
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