§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 clinical record review, observations, and staff interviews, it was determined that the facility failed to precisely and effectively monitor hydration status and implement a therapeutic diet for one of 28 residents reviewed (Residents 128). Findings include: Review of Resident 128's clinical record revealed diagnoses that included congestive heart failure (CHF - excessive body/lung fluid caused by a weakened heart muscle), emphysema (a lung disease which results in shortness of breath due to destruction and dilatation of the alveoli), and acute pulmonary edema (a condition where fluid accumulates in lung tissues, causing shortness of breath, wheezing, and coughing up blood).
Review of Resident 128's physician orders on February 26, 2024, revealed an order for, "Diet (Regular) Diet Consistency (regular) Liquid Consistency (Thin) 1200 ml (milliliter- unit of measure) fluid restriction", with a start date of January 9, 2024.
Review of Resident 128's clinical record revealed a fax from Resident 128's heart failure clinic appointment on January 29, 2024, with the following recommendations: "2300 mg (milligram- unit of measure) sodium restriction, 1800 ml fluid restriction".
Review of Resident 128's clinical record revealed an evaluation note on January 30, 2024, that stated, "Fluid restriction updated to 1800, weight changed to three times weekly and fax to HF (heart failure) clinic on Fridays."
Observation of Resident 128 in her room, eating her lunch, on February 27, 2024, at 12:36 PM, revealed she had a 240 ml can of soda on her lunch tray and mug of water on her tray table.
Observation of Resident 128 in her room, eating her breakfast, on February 28, 2024, at 9:12 AM, revealed she had a 240 ml cup of coffee on her lunch tray and mug of water on her tray table.
Observation of Resident 128 in her room, eating her lunch, on February 28, 2024, at 12:31 PM, revealed she had a 240 ml can of soda on her lunch tray, a 360 ml Styrofoam cup of water, and mug of water on her tray table.
Review of copies of Resident 128's meal tickets from lunch on February 27, 2024; breakfast on February 28, 2024; and lunch on February 28, 2024, revealed she was on a 1200 ml fluid restriction, and should only have been provided 180 ml of fluids per meal from dietary. The meal tickets failed to reveal indication that Resident 128 was on a sodium restricted diet.
During an interview with the Director of Nursing (DON) on February 28, 2024, at 1:22 PM, the surveyor requested information on how Resident 128's fluid restriction was monitored, whether it should have been 1200 ml or 1800 ml, and whether she was on a sodium restricted diet or not.
Email correspondence with the DON on February 29, 2024, at 10:40 AM, revealed they do not break down fluid restrictions by shift, and that nurse aides and licensed practical nurses document how many milliliters of fluid the resident consumes throughout the day. The DON also revealed that Resident 128 should have been following an 1800 ml fluid restriction, starting January 30, 2024, and she explained the facility process for following a sodium restricted diet.
During a follow-up interview with the DON on February 29, 2024, at 11:29 AM, the surveyor revealed the concern with Resident 128's diet order not being updated to reflect the cardiology recommendations from January 29, 2024, observations of extra fluids provided by dietary at meals, and inadequate monitoring and implementation of the fluid restriction. The surveyor inquired how the nursing staff would know how many fluids to provide the resident each shift, and the DON replied, "they wouldn't". She further revealed that Resident 128's diet order and meal tickets should have been updated to reflect the 1800 ml fluid restriction and sodium restriction.
28 Pa. Code 211.12(d)(1)(3)(5)Nursing services
| | Plan of Correction - To be completed: 04/30/2024
F0692
Resident 128 has been assessed to ensure acceptable parameters have been maintained for her individual nutritional status; including body weight and electrolyte balance.
All residents have been assessed to ensure acceptable parameters have been maintained for their individual nutritional status; including body weight and electrolyte balance.
Nursing staff and dietician have been educated on the importance of maintaining each residents individual nutritional status; including body weight and electrolyte balance.
A QA tool has been developed to review 10% residents weekly to ensure acceptable parameters have been maintained for their individual nutritional status; including body weight and electrolyte balance. The Quality Assurance (QA) Coordinator or designee will complete the QA review on a weekly basis and re-educate staff not following policy and procedure. The QA Coordinator will review the completed QA tool monthly and will report any trends or patterns at the quarterly Interdisciplinary Quality Assurance and Quality Performance (QAPI) meeting. The QAPI Committee will review the reports at their quarterly meeting and make recommendations for any deficient patterns identified. They will continue to monitor quarterly until the solutions are sustained for a period of two quarters. Decreasing or elimination of this tool will occur only upon recommendation of the Interdisciplinary QAPI Committee at their quarterly meeting.
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