§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 a review of select facility policies, the facility diet manual, clinical records, and staff interviews, it was determined that the facility failed to assess, evaluate, and monitor the nutritional parameters of residents with significant weight loss for two of 18 residents reviewed (Residents 27 and 69).
Findings include:
Review of a facility policy titled "Weight Monitoring Standards," last reviewed by the facility in October 2024, revealed if the monthly weight shows more than a 5% gain or loss, the resident is re-weighed within 24 hours. If there is an actual 5% or more gain or loss in one month, the resident, family, physician, and the Dining Services Director are notified by the Nursing Department. Documentation of the date notified should be documented in the nursing progress section of the medical record. The Dining Services Director/designee reviews the resident's nutritional status and makes recommendations for intervention in the nutrition progress notes if a significant change is noted.
Review of a facility policy titled "Weight Assessment and Intervention," last reviewed by the facility on April 15, 2025, revealed the physician and the multidisciplinary team would identify conditions and medications that may be causing anorexia, weight loss, or increasing the risk of weight loss, including medication-related adverse consequences.
A review of the clinical record revealed Resident 27 was admitted to the facility August 7, 2022, with diagnoses to include dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and chronic obstructive pulmonary disease (COPD is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe).
A quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) of Resident 27 dated May 5, 2025, revealed the resident was severely cognitively impaired with a BIMS score of 02 (brief interview for mental status, a tool to assess the residents' attention, orientation, and ability to register and recall new information, a score of 0-7 indicates severe cognitive impairment).
A review of the clinical record revealed a physician's order dated March 10, 2025, revealed an order for Senokot S 8.6-50 milligrams (mg) one tablet daily at bedtime for constipation (difficulty in bowel movements). Senekot is medication used to treat constipation with possible adverse side effect of loose stools.
A review of the clinical record revealed a physician's order dated March 26, 2025, for a mechanical soft diet. A review of a facility diet manual revealed a mechanical soft diet which per the facility's diet manual provides approximately 1600-2000 calories and 60-75 grams of protein per day at the facility.
A review of the clinical record revealed a physician's order dated March 27, 2025, for a health shake three times a day between meals to promote optimal intake (health shake- a nutritional beverage supplement that provides additional calories, protein, and essential nutrients). The facility uses a 4 oz. mighty shake which provides 200 calories and 7 grams of protein.
A review of the clinical record of a nurse progress alert note dated April 8, 2025, revealed that Resident 27 had at least three loose stools in a 24-hour period, and it was noted the resident was on medications that can contribute to lose stools.
Nurse alert progress notes dated April 28, April 29, May 5, May 12, May 13, May 16, and May 19, 2025, documented that the resident experienced at least three loose stools in a 24-hour period. The episodes were attributed to medication side effects and rectal prolapse. No adjustments were made to the resident's medication regimen, and no documentation from the physician or nurse practitioner addressed the repeated episodes of loose stools.
A review of Documentation Survey Report v2 (care tasks completed for the resident) for April 2025 until May 22, 2025, revealed that Resident 27 had experienced multiple loose stools regularly.
Review of the Medication Administration Record from April through May 22, 2025, revealed that Senokot S was administered daily, with the exception of April 7, 2025, when it was held due to lose stools. The Documentation Survey Report confirmed the resident had frequent loose stools during this time period.
A Registered Dietician (RD) note dated May 6, 2025, documented the resident experienced a 3.4-pound weight loss in 30 days, a 14-pound (11%) loss over 90 days, and a 16-pound (12%) loss over 180 days. The RD reported inconsistent meal intake (0 -25% for 2 meals; 25-50% for 6 meals; 50-75% for 3 meals; 75-100% for 10 meals; one meal was refused) and confirmed the resident was receiving health shakes three times daily. A subsequent RD note dated May 10, 2025, acknowledged the weight loss and noted Senokot S as part of the medication review. The RD noted that weight loss may be associated with natural aging process due to advanced age of 93 years old.
During an interview on May 22, 2025, at approximately 10:00 AM, Employee 2, a Certified Registered Nurse Practitioner, stated she was unaware of the recent weight loss and confirmed that although she was aware of the resident's ongoing loose stools, no hold parameters had been ordered for Senokot. She was aware Resident 27 was having loose stools regularly, but she did not want Resident 27 to end up with constipation due to the prolapsed rectum There was no documentation in the clinical record from either the physician or CRNP acknowledging or evaluating the ongoing loose stools.
Following surveyor inquiry, a new order dated May 22, 2025, was obtained to hold Senekot if the resident experienced loose stools.
Interview with the Regional Nurse Consultant on May 22, 2025, at approximately 12:50 PM, confirmed the facility failed to recognize contributing factors including frequent loose stools, that may have contributed to Resident 27's significant weight loss.
A review of Resident 69's clinical record revealed admission to the facility on December 26, 2023, with diagnoses to include Alzheimer's Disease (a progressive brain disease that destroys memory and other important mental functions), and adult failure to thrive (a global decline in health often characterized by weight loss, decreased appetite, poor nutrition, and reduced physical activity).
A review of the resident's weights noted the following:
January 4, 2025 - 182.4 lbs.
February 4, 2025 - 163.2 lbs. indicating a 19.2 lb. weight loss or 10.53% loss of body weight.
There was no documented evidence the resident was reweighed within 24 hours as required by facility policy. Additionally, there was no documentation that the physician, resident representative, or Dining Services Director/designee were notified of the significant weight loss. There was also no documentation to indicate that the resident's nutritional status was reviewed or that interventions were recommended by the Dining Services Director.
During an interview on May 22, 2025, at approximately 12:50 PM, the Regional Nurse Consultant confirmed that the facility failed to obtain a reweight and failed to timely notify the physician, RP, and Dining Services Director regarding the resident's weight loss. She acknowledged that the facility lacked necessary information to accurately assess Resident 69's nutritional status, evaluate intake adequacy, and plan for appropriate nutritional support.
28 Pa Code 211.5(f)(ix) Medical records
28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services
| | Plan of Correction - To be completed: 07/08/2025
1.Facility can not retroactively correct.
Resident 27-Physician order for Senokot S was reviewed and modified on May 22, 2025, to include hold parameters in the presence of loose stools. The resident's weight loss and loose stools were reviewed by the Registered Dietitian, CRNP, and Nursing, and the care plan was updated on to reflect new interventions including:
Monitoring for stool frequency and consistency daily. Nutritional intake monitoring with weekly weights. Enhanced nutritional support, including health shakes and fortified foods.
Resident 69:Facility can not retroactively correct. Physician, RP, and Dietician were notified of the weight loss. A nutrition consult was obtained, and interventions were implemented based on the RD's recommendations. Care plan was revised to reflect nutritional risk, and weight monitoring.
2.Registered Dietician will conduct a facility-wide audit of current residents with 5% or greater weight loss over 30 days or 10% or greater over 90 days.
Residents who are identified will be reweighed if a second weight was not on file within 24 hours of the original flagged weight and reviewed by the RD, and interventions will be updated accordingly.
updates will also include documentation reflecting physician/RP notification and revised care plans.
3.DON/Designee will educate licensed nursing staff and IDT on the facility's policies titled "Weight Monitoring Standards" and "Weight Assessment and Intervention", with emphasis on:
Timely reweights after significant gains/losses. Physician, RP, and Dietary Services notification.Thorough documentation reflecting this in the residents chart. IDT and Dietician will be educated on PCC dashboard that triggers a new weight loss/gain when weight thresholds are exceeded.
4.The Director of Nursing and Dietary Manager/designee will audit up to 5 weight changes weekly for 4 weeks than monthly to verify timely reweighs, notifications, interventions, and documentation.
Audit results will be reviewed during monthly QAPI meetings.The Registered Dietitian will provide monthly reviews of all significant weight changes, with oversight by the QAA Committee.
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