The findings of the complaint health survey (Intake #27826) conducted from 3/11/21 through 3/15/21 are documented in this report. The survey was conducted to determine compliance with 42 CFR Part §483 Requirements for Long Term Care Facilities.
The sample was comprised of 2 current residents and 1 closed record. The facility had a census of 27 residents.
Abbreviations possibly used in this document:
ADL: activities of daily living
bid: twice a day
BIMS: Brief Interview for Mental Status
CAA: Care Area Assessment
CBG: capillary blood glucose or
blood sugar
cm: centimeter
CMA: Certified Medication Aide
CNA: Certified Nursing Assistant
CPR: Cardiopulmonary Resuscitation
DNS: Director of Nursing Services
F: Fahrenheit
FRI: Facility Reported Incident
HS or hs: hour of sleep
LPN: Licensed Practical Nurse
MAR: Medication Administration
Record
mcg: microgram
MDS: Minimum Data Set
mg: milligram
ml: milliliters
O2 sats: oxygen saturation in the
blood
OT: Occupational Therapist
PCP: Primary Care Physician
PO: by mouth, orally
PRN: as needed
PT: Physical Therapist
RA: Restorative Aide
RAI: Resident Assessment
Instrument
RD: Registered Dietician
ROM: range of motion
RN: Registered Nurse
RNCM: Registered Nurse Care
Manager
SLP: Speech Language
Pathologist
TAR: Treatment Administration
Record
tid: three times a day
UA: Urinary Analysis
UTI: urinary tract infection
The findings of the complaint (Intake #27826) health revisit survey conducted 4/16/21 are documented in this report. The facility was found to be in substantial compliance with 42 CFR Part §483 Requirements for Long Term Care Facilities.
Based on interview and record review it was determined the facility failed to ensure resident nutritional needs were met related to appropriate nutritional supplements and weight monitoring for 1 of 3 sampled residents (#1) reviewed for nutrition. This placed residents at risk for increased blood glucose and unplanned weight loss or gain. Findings include:
Resident 1 admitted to the facility in 12/2020 with diagnoses including diabetes.
The 12/7/20 Admission MDS indicated Resident 1 was cognitively intact and received a therapeutic diet.
a. Resident 1's 12/1/20 Admission Orders indicated to provide Ensure (high calorie nutritional supplement) with meals.
The 12/2020 TAR indicated Resident 1 received a high calorie nutritional supplement with meals beginning on 12/1/20.
A 12/2/20 Nutrition Assessment indicated a recommendation to discontinue the high calorie nutritional supplement due to Resident 1's diagnosis of diabetes.
No information was found in the resident's clinical record to indicate the recommendation to discontinue the high calorie supplement was addressed until 12/7/20.
The 12/2020 TAR indicated Resident 1 stopped receiving the high calorie nutritional supplement on 12/7/20 (five days later) and began to receive a sugar-free nutritional supplement.
On 3/11/21 at 11:41 AM Witness 1 (Complainant) stated Resident 1 was not supposed to receive a high calorie supplement and needed a sugar-free supplement instead. Witness 1 stated Resident 1 talked with nursing staff about the need for a sugar-free supplement several times before the order was changed.
On 3/12/21 at 3:06 PM Staff 2 (DNS) acknowledged Resident 1 continued to receive the high-calorie supplement for five days after it was recommended to be discontinued. Staff 2 was not able to provide a rationale for why the high calorie supplement continued to be provided to Resident 1.
b. Resident 1's care plan for nutrition, initiated on 12/1/20, indicated a goal of no unplanned significant weight loss or gain. Interventions included to monitor the resident's weights per facility protocol.
The 12/2/20 Nutrition Assessment indicated to monitor Resident 1's weights.
Weight records indicated Resident 1 was weighed on 12/1/20 but no evidence was found to indicate the resident was weighed at any other time.
On 3/15/21 at 12:22 PM Staff 2 (DNS) stated the facility protocol was to weigh residents daily for three days, then weekly for one month, and then monthly. Staff 2 acknowledged there was no evidence the facility monitored Resident 1's weights.
1. Resident is no longer in the center.2. Residents weights will be monitored to validate they are being done per policy.Review done of current residents to validate their weights are current and being obtained as ordered if they have an order for weight frequency beyond facility protocol. Review done of Registered Dietitian recommendations for supplements or supplement changes in past 30 days to validate they have been followed up on timely.3. Licensed Nurses will be re-educated on weight policy and timely follow up on RD recommendations.Nutrition Hydration Skin Committee members will be educated on updated process to include review and validation of prior weeks recommendations at start of each meeting. Nutrition Hydration Skin Committee meeting process updated to include a validation that recommendations made the previous week have been addressed. 4. DNS or designee will audit weights and recommendations for timely completion weekly for 4 weeks and monthly for 2 months. 5. Compliance Date: 4/8/2021
The findings of the complaint health survey (Intake #27826) conducted from 3/11/21 through 3/15/21 are documented in this report. The survey was conducted to determine compliance with OAR 411 - 85 through 89. For additional information refer to the Form CMS 2567 dated 3/15/21
Abbreviations possibly used in this document:
ADL: activities of daily living
bid: twice a day
BIMS: Brief Interview for Mental Status
CAA: Care Area Assessment
CBG: capillary blood glucose or blood sugar
cm: centimeter
CMA: Certified Medication Aide
CNA: Certified Nursing Assistant
CPR: Cardiopulmonary Resuscitation
DNS: Director of Nursing Services
F: Fahrenheit
FRI: Facility Reported Incident
HS or hs: hour of sleep
LPN: Licensed Practical Nurse
MAR: Medication Administration Record
mcg: microgram
MDS: Minimum Data Set
mg: milligram
ml: milliliters
O2 sats: oxygen saturation in the blood
OT: Occupational Therapist
PCP: Primary Care Physician
PO: by mouth, orally
PRN: as needed
PT: Physical Therapist
RA: Restorative Aide
RAI: Resident Assessment Instrument
RD: Registered Dietitian
ROM: range of motion
RN: Registered Nurse
RNCM: Registered Nurse Care Manager
SA: State Agency
SLP: Speech Language Pathologist
TAR: Treatment Administration Record
tid: three times a day
UA: Urinary Analysis
UTI: Urinary Tract Infection
The findings of the complaint (Intake #27826) health revisit survey conducted 4/16/21 are documented in this report. The facility was found to be in substantial compliance with OAR 411 Divisions 85 through 89.
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OAR 411-086-0140 Nursing Services: Problem Resolution & Preventive Care
Refer to F692
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