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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 21, 2021
Corrected date: August 11, 2021
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the recertification and abbreviated surveys (NY 439) conducted on [DATE] to [DATE], the facility failed to ensure residents maintained acceptable parameters of nutritional status for 1 of 7 residents (Resident #208) reviewed. Specifically, for Resident #208 who had significant weight loss, the family's request to bring in outside meals was not accommodated by the facility and a medical order for a [MEDICATION NAME] consult for a percutaneous endoscopic gastrostomy (PEG, feeding tube) insertion was not implemented by the facility. Findings include: The facility Nutrition Assessment Process Policy, dated ,[DATE], documented the purpose of the nutrition assessment is to gain pertinent important information in order to adequately manage and prevent nutrition related health conditions. The facility Nutritional Policy for High Risk Residents, revised [DATE], documented residents are considered high risk if they have one or more of the following concerns: feeding tube; impaired skin integrity significant weight change, and [MEDICAL TREATMENT] treatments. The policy listed multiple potential interventions the registered dietitian (RD) could consider and documented the RD will update the comprehensive care plan (CCP) and inform the interdisciplinary team (IDT) of the problem via email. Interventions will be monitored for success or failure within 1 week of initiation. The facility's Food Brought in From Outside Sources policy, revised ,[DATE], documented residents have the right to choose when and what to eat. Therefore, food may be brought in for residents by family or visitors. The policy outlined appropriate storage of food brought in from outside sources and documented if residents could not access the food on their own, staff were to assist. The facility Change in Condition policy, revised ,[DATE], documented the Nurse Supervisor/Charge Nurse will notify the resident's attending physician or on-call physician when there has been: - A significant change in the resident's physical/emotional/mental condition; and - A need to alter the resident's medical treatment significantly. Any changes in the resident's condition will be reported to the Physician/ Practitioner and all Physician/Practitioner orders will be initiated. Resident #208 was admitted to the facility with [DIAGNOSES REDACTED]. The [DATE] Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment, required supervision and set-up at meals, weighed 106 pounds, received a therapeutic diet, and had a significant unplanned weight loss of 5% or greater at one month or 10% or greater at six months. Prior to admission, on [DATE], the resident designated their family member and their family member's spouse to be their health care proxy (HCP) in the event they could not make their own medical decisions. The [DATE] admission assessment documented the resident weighed 115.2 pounds. The Medical Orders for Life Sustaining Treatment (MOLST), dated [DATE], documented the resident verbally consented to a full code (cardiopulmonary resuscitation, CPR, in the event the heart stopped) order, wanted no limitations on medical interventions, and wanted a trial period of artificially administered intravenous (IV) fluids and nutrition. The [DATE] nutrition progress note documented the resident's diet order was gluten free. The [DATE] History and Physical documented the resident weighed 115.2 pounds with a history of FTT. The resident was deemed not competent to make medical decisions and the HCP was their decision-maker. Nurse practitioner (NP) #20's progress notes documented: - on [DATE], the resident was significantly hypotensive (low blood pressure), on the cusp of [MEDICAL CONDITION](rapid heart rate), reported dizziness and lightheadness upon standing likely from orthostatic drop (blood pressure decrease when standing). Nursing reported to NP #20, the resident had no meaningful intake for 3 days. The resident reported they were waiting for organic products and was afraid of chemicals in food. The resident had a history of [REDACTED]. NP #20 ordered intravenous (IV) fluids and labs. - On [DATE], the resident had no intake for 4 days. The resident refused the IV fluids and labs ordered the prior day and refused again today. NP #20 ordered for the resident to go to the hospital for likely dehydration and inadequate caloric intake. The [DATE] registered nurse (RN) #1's progress note documented Resident #208 returned to the facility after being hydrated in the emergency room . The resident was readmitted to a different room as the resident previously reported their roommate was very loud, making the resident unable to eat. The [DATE] and [DATE] nutrition progress notes documented the resident's family brought in an organic nutrition supplement (shake). The resident refused Ensure (supplement) and other fortified foods due to their chemical and sugar content. The resident added multiple foods to their dislike list and agreed to bottled water, organic applesauce, and apple juice. There was no documentation in the nutrition note that the resident's nutritional needs (calories/protein) had been assessed since admission and no documentation regarding the nutritional value of the shakes brought in by the family or how often the resident was to consume the shakes. On [DATE], NP #20's progress note documented the resident continued with poor intake and intake was not sufficient to maintain their metabolic needs. The resident again cited concerns with chemicals in food and other irrational reasoning behind not eating. The resident received routine anti-psychotic and anti-anxiety medications and the NP noted in the past, there was a court order for PEG tube placement for the resident and the tube was not placed when the resident agreed to eat. NP #20 asked the social worker to investigate whether the court order was current as the resident needed a PEG tube. On [DATE], diet technician (DT) #24's progress note documented the resident was transferred to a long-term care unit and requested organic applesauce, which the DT told the resident the facility did not have. The resident was provided with their own Greek yogurt from the refrigerator. The resident had their vegan drink at bedside. On [DATE], NP #20's progress note documented the resident continued with poor intakes. The social worker was investigating the prior court order for PEG tube insertion. The resident appeared frail and thin. DT #24's progress notes documented on [DATE] and [DATE], the resident ate and drank the foods/fluids their significant other brought to the facility for them and on [DATE], the significant other brought in more organic shakes and baby food. On [DATE], Director of Social Services #22's progress note documented the resident's significant other came to the facility and demanded the resident be released to their custody. The significant other was not the HCP and the resident did not want to see their significant other. Administration called the police to escort the resident off of the property. The significant other was no longer allowed on the property and a trespassing order was on file with the police. The note contained no documentation in regard to the social worker investigating the prior court order for the PEG tube for the resident. The weight record documented on [DATE], the resident weighed 104 pounds (11.2 pound/9.72% loss in 5 weeks). On [DATE], DT #24's progress note documented the resident requested puree foods, the Nurse Manager was made aware, and the meal pattern was adjusted. The weight record documented on [DATE], the resident refused to be weighed. On [DATE] NP #20's progress note documented the resident was continually loosing weight. The resident recently requested puree consistency foods as their significant other, who was brining in baby food, was no longer allowed to visit. NP #20 planned to follow-up with social work again about the prior court order for PEG tube insertion. The attending physician's orders [REDACTED]. - on [DATE] physician's orders [REDACTED]. - on [DATE], the diet order was gluten free with pureed consistency solids per resident request. The resident was to receive 30 milliliters (ml) of a protein supplement once daily for a [DIAGNOSES REDACTED]. The weight record documented on [DATE], the resident weighed 95 pounds (9 pound/8.65% loss in 2 weeks). On [DATE] the complainant reported, the RD asked them to bring in food for the resident because they lost so much weight. The significant other was so shocked to see how thin the resident was, they took a picture, and called the police and an ambulance to have the resident removed from the facility. The facility then barred the significant other from visiting. Since the visit, they tried to deliver food for the resident and had been turned away. They stated they also tried a meal delivery service as they knew facility staff received food deliveries and they were turned away too. On [DATE], RD #33's progress note documented the resident had significant weight loss despite interventions. RD #33 documented all avenues that nutrition services could do have been tried to maintain adequate nutrition status had been tried and a PEG tube was recommended. On [DATE], NP #20's progress note documented the [MEDICATION NAME] consult was ordered and they were awaiting an appointment. On [DATE], Director of Social Services #22's progress note documented during a family meeting, the resident's poor intakes and weight loss were discussed. The resident Nursing, medical, and nutrition were to confer regarding the next best course of action. There was no documentation the social worker was looking into the resident's prior court order for the PEG tube placement. On [DATE] and [DATE] the complainant reported, they were informed by the facility they were placing a feeding tube in the resident due to poor intake and weight loss. They reported the resident would not eat institutional food and the staff said they could bring in food for the resident. They reported when they tried to bring food or have it delivered, even though they were told it was okay, they were turned away at the front desk. On [DATE], attending physician #30's progress note documented the resident reported no new concerns or complaints. A medical [DIAGNOSES REDACTED]. The weight record documented on [DATE], the resident weighed 90.8 pounds (4.2 pounds/4.42% loss over 15 days). The resident weighed 115.2 pounds on admission on [DATE]. The comprehensive care plan (CCP), reviewed on [DATE], documented the resident was at risk for altered nutritional status related to stated gluten intolerance, significant weight loss, avoidance and restrictive food intake disorder, severe protein-calorie malnutrition, low body mass index (BMI), refusal of most nutrition supplements and fortified foods. Interventions included updating meal preferences, providing gluten free and puree food, organic nutritional supplements, and other food family can provide which resident may consume. On [DATE] at 9 AM, a sign was observed at both visitor screening stations in the main lobby. The sign documented Attention visitors no food or beverage allowed. On [DATE] at 10:02 AM, Resident #208 was observed in their room lying in bed. They were thin in appearance. There was a breakfast tray on the over the bed table that contained a 2 oz. bowl of puree scrambled eggs, 6 oz. bowl of puree hot cereal, 4 oz. of unopened of apple juice, 8 oz of unopened skim milk, and 4 oz of opened applesauce. Twenty five percent of the solid food was consumed. The resident stated in an interview at that time, the food was good as could be expected, they had weight loss, but were unsure how much weight they lost. The resident reported they would like to choose their foods and wanted outside food delivered to them. They reported in the past, their significant other brought in organic juice and a lot of other foods and beverages. On [DATE] 9:32 AM, Resident #208 was observed sitting on the side of their bed eating a jar of puree green beans and drinking an organic nutrition supplement. The meal ticket documented the resident was on a gluten free puree diet. The resident received the following on their meal tray: 4 oz of water in a cup with the lid on, 8 oz of skim milk opened, 2 oz of puree eggs, 6 oz of a hot cereal, and 4 oz of apple sauce. The resident reported the puree green beans and juice boxes were brought in by their significant other. On [DATE] 1:54 PM, Resident #208 was observed in their room, sitting in the wheelchair with the lunch tray in front to them. The resident received and consumed the following items: 4 oz water, unopened, 0% consumed; 8 oz skim milk, 25% was consumed; 4 oz of apple juice, 0% consumed; 3 oz puree chicken, 25% consumed; 4 oz puree carrots, 0% consumed; 4 oz puree peaches, 100% consumed, 4oz applesauce, 0% consumed; 4 oz vanilla yogurt, 0% consumed, and 8 oz organic nutrition supplement, unopened, 0% consumed. All foods were in Styrofoam containers and the resident reported eating out of Styrofoam containers made them sick. During telephone interviews with the resident's HCP on [DATE] at 5:02 PM and [DATE] at 8:06 AM, they stated the resident at baseline ate healthy organic food and was a picky eater. The resident's significant other could bring in prepackaged foods, such as baby food for the resident but not prepared food as the facility did not permit that. The HCP was aware the resident lost weight and knew they needed a PEG tube to help meet their nutritional needs. The HCP reported the PEG tube insertion was discussed at a care plan meeting (on [DATE]), they were told an appointment was pending, and they had not heard back from the facility regarding the appointment yet. The HCP stated it had been a couple of weeks since they heard anything from the facility. On [DATE] at 5:58 PM, a food delivery from a local restaurant was observed on the desk in the main lobby. At that time, Receptionist #31 (who was sitting next to the food delivery bag) was interviewed and reported residents could not receive any outside food deliveries, including pre-packed foods and take out meals. If a resident received a food delivery, they turned it away. Receptionist #31 did not have a copy of the facility policy related to outside food and stated if people had questions or concerns they were referred to the Director of Operations or Nursing Supervisor in the off-hours. Receptionist #31 then provided conflicting information and stated some residents could accept food deliveries but there was no list of which residents could receive deliveries. Receptionist #31 told the surveyor the food delivery at the desk at that time was food for the Director of Operations and they referred the surveyor to the Director of Operations for more information. During an interview with the Director of Operations on [DATE] at 3:36 PM, they stated per Administration, the facility could not accept food deliveries for residents. They turned away food deliveries in the past and then the resident was notified of this by unit staff. There could be exceptions to this made by administration. They were unsure if staff could have food delivered to the facility and had not ever witnessed food being delivered to the facility for a staff member. During an interview with CNA #32 on [DATE] at 10:30 AM, they reported they were told residents could not receive take out orders and staff were allowed to. They reported Resident #208 needed encouragement at meals, intakes were variable, the resident received a special organic nutrition supplement that they sip on throughout the day and had special tea in their room they could ask for. During an interview with DT #24 on [DATE] at 10:45 AM, they stated residents were allowed to receive food packages via the mail but food could not be brought to the facility by families or delivery drivers. Resident #208's significant other was dropping off items the resident liked, such as cookies, different beverages, and baby food, but they had not dropped off items recently and they were unsure why. The resident was a poor eater and interventions had been trialed without success. DT #24 reported they told everyone including NP #20, RD #33, and RN Manager #34 about the resident's weight loss and there was a [MEDICATION NAME] consult ordered for PEG tube insertion. During an interview with RD #33 on [DATE] at 11:42 AM, they reported Resident #208 was a picky eater, who had refused to eat and had [DIAGNOSES REDACTED]. The resident was provided an organic nutrition supplement. The resident was not meeting their caloric needs and needed a PEG tube inserted. There was a consult placed to for a PEG tube insertion, but they were unsure if the appointment had been scheduled at this time. Residents were allowed to receive mail ordered food packages but could not receive any food deliveries via the main entrance. This has been going on since the start of the pandemic and Administration created the no outside food policy. During an interview with RN Manager #34 on [DATE] at 12:42 PM, they stated the resident was being followed by psychology and was going to see a psychiatrist on [DATE]. They were also looking into a PEG tube placement. When the consult for the [MEDICATION NAME] was ordered on [DATE], RN #34 googled [MEDICATION NAME] and called the first name that came up in their online search. When RN #34 called they were told the resident had seen this provider in the past, had canceled appointments previously, and the provider was unsure if they would accept the resident again. The provider was supposed to call the facility back when a decision was made. RN #34 had not yet heard back from the [MEDICATION NAME] office and then RN #34 went on vacation. RN #34 did not know who covered for them when they were on vacation. RN #34 stated the resident would eat for a bit, was not capable of making their own medical decisions, and their MOLST documented they wanted a trial of artificial nutrition and hydration. RN #34 stated it was a long time for someone in the resident's condition to wait for a [MEDICATION NAME] appointment. During an interview with Director of Social Services #22 on [DATE] at 4:45 PM, they stated residents could receive food care packages, if they were diet appropriate, via the mail and prepackaged foods could be dropped off during a scheduled visit. No one was allowed to get take out food at this time, including staff. This policy had been in place due to the COVID-19 pandemic and was in place prior them starting at the facility. The Director of Social Services #22 stated, they felt it was a resident right's issue if residents were not allowed to receive take out food and staff could. They reported nutrition staff spoke with Resident #208's HCP due to their concerns and they were aware an order had been placed for a consult for PEG Tube insertion. The Director of Social Services stated staff should be discussing PEG tube insertion with the HCP. During a telephone interview with NP #20 on [DATE] 12:45 PM, they reported Resident #208 had a prior court order for a PEG tube insertion. The resident ate organic foods, drank bottled water, and ate baby food. The resident was followed by psychology. NP #20 stated the HCP was agreeable to a PEG tube and the consult was ordered on [DATE] and the appointment was pending. NP #20 was unaware there had been a delay in scheduling the appointment and would have expected to be notified that the consult was not scheduled yet. During an interview with the facility Administrator on [DATE] at 4:24 PM, they reported it was case by case for outside food. The facility just came off of a 14-day restriction quarantine related to a staff member testing positive. No take out deliveries were allowed during the COVID-19 lock down due to infection control. The residents could receive unopened prepackaged foods in the mail They reported the facility was just starting to open up and this would be discussed next week during the quality assurance meeting. During a telephone interview on [DATE] 12:50 PM, attending physician #30 stated they seen the resident once since the resident moved to the long-term care unit. They reported NP #20 had not reached out to them regarding this resident's consult. The attending physician stated with a consult of this nature, they would have expected to be notified of the delay because they would have helped to try and get an appointment sooner and the delayed appointment could have led to more weight loss. They stated if they were aware of the situation, they would have followed up with the patient again. They reported they would expect this type of consult to be completed sooner rather than later. 10NYCRR415.12(i)1 | Plan of Correction: ApprovedOctober 1, 2021 F692 Nutrition/Hydration Status Maintenance What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The Assistant Administrator has spoken with resident #208?s husband and the Ombudsman to clarify the misunderstanding stemming from the husband?s ban from the building; clarifying the husband?s ability to have resident #208?s preferred food to be delivered to the facility regardless of the ban. The Facility has verified with the resident that she is currently receiving her preferred food items from her husband and they are present in her room. Resident #208 will be seen by nutrition staff weekly to review food preference. Resident #208 has been determined by the Medical Director to have capacity. Her MOLST has been reviewed with her and she has indicated her wishes that she does not want a tube feeding. This has been reviewed with the HCP who voices understanding and is in agreement with following the resident?s wishes. In the interim, the GI consult appointment remains scheduled and the resident is on the GI providers? cancellation list should an earlier appointment become available. At this time, resident #208 is in agreement to keep the GI consult appointment and understands her right to change her mind regarding the feeding tube. The psychologist continues with routine follow up. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents have the potential to be affected by the same deficient practice. The facility is monitoring the COVID-19 prevalence in the community, Delta variant and resident vaccination rates prior to resuming the outside food delivery pre-pandemic policy. The facility continues to allow pre-packed food delivery. All residents with capacity and/or HCP with persistent unplanned weight loss will have their advanced directives reviewed for their wishes on artificial nutrition. Those residents that have requested to have a feeding tube placed on their Advance Directive will be reviewed by Medical to determine if a GI consult is needed. All residents with current orders for GI consults for feeding tube placement will be reviewed to ensure there is an appointment scheduled. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not occur? All Administration, RN Managers, RN ADON, RN DON, and Facility Security Staff will be educated on the ?Food from outside sources policy? The Facility Policy for Food from outside Sources will be incorporated into the Facility Admission packet and added to the Facility Website. The RN Managers/Supervisors will be educated on communication to the ordering medical provider of scheduled date for consult appointment and medical will determine if appointment is timely. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice? Registered Dietitian or designee will complete weekly audits of 20 residents to determine if they received food from outside sources if they requested Registered Dietitian will audit all GI consult orders for PEG tube placement weekly X 3 months to determine that all orders have scheduled appointments Results of the audits will be reviewed at QA until the QAPI Committee determines an appropriate level of compliance where the frequency of the audit may be reduced. The efficacy of the corrective measures will be monitored by the Quality Assurance Performance Improvement Committee Overseen by: Director of Clinical Nutrition Correction Date: (MONTH) 11, 2021 |