§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 clinical records, select facility policy, and staff interview it was determined the facility failed to monitor and evaluate weight and hydration requirements of a resident to ensure acceptable parameters of nutritional status are maintained to the extent possible for one resident out of six sampled (Resident A1).
Findings include:
Review of the facility Resident Weight Policy last reviewed December 2024 indicated weights must be obtained routinely to monitor nutritional health over time. Each resident's weight will be determined upon admission/readmission to the facility, weekly for the first four weeks after admission/readmission, and monthly or more often if risk is identified, or as ordered.
Review of the Resident Hydration Policy last reviewed December 2024 indicated residents will be offered/administered sufficient fluid intake to maintain hydration. A variety of fluids will be offered to residents, depending on preference and nutritional/diagnosis considerations. A dietitian will evaluate resident fluid status within 14 days of admission, quarterly, and as needed. This may include laboratory testing by the provider as ordered. Fluids include water, juices, coffee/tea, gelatin, ice cream, soups, popsicles, and any other substance which is essentially liquid in nature. Nursing staff will be primarily responsible for resident fluid intake during and between meals. Fluids may be provided by others determined by resident fluid and dietary orders (such as activities, dietary, visitors). Nursing, medical providers, and dietitians will monitor for signs of dehydration and monitor resident medications which may alter fluid balance. Fluids will be provided with meals, snacks, and at the bedside, unless otherwise ordered by the provider. If resident fluid status is identified as inadequate, the interdisciplinary team will discuss with the resident and provider and determine if alternative (non-oral) methods of hydration are desired/warranted.
A review of the clinical record revealed Resident A1 was admitted to the facility on October 18, 2024, with diagnoses which included dementia, congestive heart failure (chronic condition in which the heart does not pump blood as well as it should), and chronic kidney disease (disease characterized by progressive damage and loss of function to the kidneys).
A review of the resident's quarterly Minimum Data Set Assessment (MDS- a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated December 3, 2024, indicated the resident was severely cognitively impaired with a BIMS (brief screener that aids in detecting cognitive impairment) score of 0 (a score of 0-7 indicates severe cognitive impairment).
A physician order dated October 19, 2024, noted an order for Furosemide (a diuretic or water pill, used to treat a build- up of fluid in the body which increases urination and may increase risk for dehydration) 20 mg one tablet by mouth daily for a diagnosis of edema (buildup of fluid in the body's tissue).
Review of a Medical Nutritional Therapy Observation and Admission Nutrition Assessment dated October 21, 2024, indicated the resident was prescribed a Regular diet and consumed 76-100% of food and fluids. The resident's calorie needs were 1375-1650 kcal per day and fluid needs were 1375 ml-1650 ml per day. The resident was noted to have non-blanchable areas (area of redness on the skin that does not turn white when pressure is applied) to the sacrum and right upper back. The resident's nutrition goals were stable weight, stable or improved skin, and adequate hydration. A nutrition intervention of 90 ml med pass (nutritional supplement) every day was recommended.
A review of the resident's weights noted the resident experienced weight loss as follows:
October 18, 2024- 114 pounds
October 23, 2024- 107 pounds (which indicated a 7-pound significant weight loss (defined as 5% loss of body weight in one month interval) or 6.1% loss of body weight in one week.
A dietary note dated October 25, 2024, noted current weight shows 7 pounds, 6.1 % weight loss in the first week of admission. No fluid changes noted. BMI (body mass index a screening tool based on height and weight to evaluate weight categories) indicates low body weight. Meal intake variable but greater than 50% intake of many meals. 90 ml med pass in place every day. Supplement accepted two of three offerings. Resident has impaired skin. Recommend Mighty Shake every day to promote weight stability and adequate oral intake for wound healing.
Further review of the resident's weights noted the following:
October 29, 2024- 106 pounds
November 5, 2024- 104 pounds
November 12, 2024- 104 pounds
November 19, 2024- 98.6 pounds which indicated a 5.4-pound significant weight loss or 5.1% loss of body weight in one week.
There was no documented evidence of a reweight to verify the weight loss or that the dietitian evaluated the resident following the significant weight changes.
There was no documented evidence of physician or resident representative notification of the weight changes.
Review of the resident's appetite record from December 1 through December 9, 2024, indicated the resident was consuming less than 75 % at most meals.
Review of the resident's fluid intake from December 1 through December 9, 2024, indicated the following:
December 1, 2024- 1140 cc fluids (with and between meals) and 76-100% supplements.
December 2, 2024- 520 cc fluids (with and between meals) and 76-100% supplements.
December 3, 2024- 760 cc fluids (with and between meals) and 76-100% supplements.
December 4, 2024- 720 cc fluids (with and between meals) and 76-100% supplements.
December 5, 2024- 320 cc fluids (with and between meals) and 76-100% supplements.
December 6, 2024- 700 cc fluids (with and between meals) and 76-100% supplements.
December 7, 2024- 720 cc fluids (with and between meals) and 26-50% supplements.
December 8, 2024- 720 cc fluids (with and between meals) and 1-100% supplements.
December 9, 2024- 720 cc fluids (with and between meals) and 76-100% supplements.
From December 1 to December 9, 2024, the resident's fluid intake ranged from 320 cc to 1140 cc per day, consistently below the required range of 1375-1650 ml/day.
There was no documented evidence based on the resident's weight loss, decreased appetite, decreased fluid intake, and diuretic use that the facility was timely monitoring and evaluating the resident's appetite and fluid intake to ensure the resident's caloric and fluid needs were met to the extent possible.
A nurses note dated December 9, 2024, at 12:16 PM noted the resident was documented as lethargic with poor appetite. A nurse's note indicated the physician was notified, and labs were ordered along with a urinalysis with C&S (culture and sensitivity). The resident's diet was downgraded to a pureed texture.
A nurses note dated December 10, 2024, at 3:02 PM noted lab results received. Physician called due to high abnormal lab results. Per physician resident is to be sent to emergency department for intravenous fluids and further evaluation.
Review of the resident's lab results dated December 10, 2024, showed significantly elevated BUN 144 mg/dL (normal value 7-25 mg/dL, may be elevated with dehydration); Creatinine was elevated at 3.14 mg/dL (normal value 0.40-1.10 mg/dL, may be elevated with dehydration); Sodium elevated at 167 mmol/L (normal value 135-145 mmol/L, may be elevated with dehydration); and Chloride elevated at 127 mmol/L (normal value 100-109 mmol/L, may be elevated with dehydration).
Review of the hospital discharge summary dated December 13, 2024, revealed the resident was admitted to the hospital for treatment of hypernatremia likely secondary to fluid deficit secondary to diuretic use, acute kidney injury superimposed on chronic kidney disease secondary to fluid deficit secondary to diuretic, and urinary tract infection.
The resident was readmitted from the hospital to the facility on December 13, 2024.
There was no documented evidence the facility identified or addressed the resident's significant weight loss and inadequate fluid intake.
Interview with the director of nursing on January 3, 2024, at approximately 12:00 PM failed to provide documented evidence that the facility timely identified the resident's significant weight loss and decreased oral intake and, nor did they reassess nutritional, and hydration needs to ensure the resident's nutritional parameters were maintained and plan nutritional support as necessary.
28 Pa. Code 211.5 (f) (ii) (ix) Medical Records.
28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.
| | Plan of Correction - To be completed: 01/21/2025
Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.
Step 1
RA1 was discharged on 1/4/2025
Step 2
To identify other residents that have the potential to be affected, the DON / designee audited current in house residents for significant weight changes. Those identified with significant weight changes were addressed as necessary. Current residents were assessed by nursing for hydration status via visual observation. Follow up completed based on findings of the audits as needed.
Step 3
To prevent this from reoccurring, the DON / designee will educate nursing staff on s/s of dehydration and weight policy. The Registered Dietician will be educated by the Regional Dietician on the weight policy.
Step 4
To monitor and maintain compliance, the DON / designee will randomly audit 25 residents per day to review weight, meal consumption, and fluid intake to ensure concerns related to hydration and significant weight changes are addressed. The audits will be completed 5 days per week times 4, then weekly times 4, then monthly times 3. The results of the audits will be forwarded to QAPI committee for further review and recommendations.
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