cms_WV: 4743
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4743 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2016-07-07 | 325 | D | 1 | 0 | R67611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to ensure two (2) of eleven (11) resident's records reviewed for the care area of nutritional status, maintained acceptable parameters of nutrition. For Resident #5, the facility failed to monitor the resident's significant weight loss (18 pounds in 30 days), and failed to ensure interventions implemented to address the resident's significant weight loss, remained in place. The facility failed to address Resident #9's (who is feed via a Percutaneous endoscopic gastrostomy (PEG) tube) 5 % weight loss and failed to monitor the resident's weight after admission for four (4) weeks to ensure further weight loss did not occur. Resident identifiers: #5 and #9. Facility census: 113. Findings include: a) Resident #5 Record review of the resident's weights at 7:30 a.m. on 07/07/16, found the following documented weights in the electronic medical record: --04/04/16-107 pounds --05/03/16 - 88.9 pounds --05/10/16 - 91.8 pounds --05/19/16 - 90.2 pounds --05/26/16 - 85 pounds --06/01/16 - 88.5 pounds --06/07/16 - 86.2 pounds --06/16/16 - 86.2 pounds --06/21/16 - 88.5 pounds --07/01/16 - 88.6 pounds The most recent nutritional assessment, completed on 04/27/16, by a registered dietician, revealed the following for Resident #5: --The resident's height was 63 inches and her weight was 107.0 pounds --The resident received a pureed diet with limitation of potassium rich foods. --A supplement previously initiated, but discontinued due to the resident's improved intake and weight gain. --The resident received a snack at 2:00 p.m. --The resident's previous weight loss and underweight body mass index was noted. --However, the resident's current weight at 107 pounds triggered as a significant gain. --The resident's body mass index noted as now within healthy limits, weight gain desirable --The resident noted as currently eating/drinking well with desirable weight gain. Review of the nursing notes found a, weight warning, note dated 05/06/16. The note indicated the resident had a continual and gradual weight loss despite the snacks and regular meals orders, and the assistance with eating. The noted indicated physician notification. On 05/10/16 an order was written to discontinue the residents snack and start a house supplement, two (2) times a day, at 10:00 a.m. and 2:00 p.m. through 06/10/16. The Medication Administration Record [REDACTED]. From 05/12/16 to 05/31/16 the resident consumed the following percentages of the house supplement: --05/12/16 - 100% of the supplement was consumed at 10:00 a.m. and 2:00 p.m. --05/13/16 - 100% of the supplement was consumed at 10:00 a.m. and 2:00 p.m. --05/14/16 - 50% of the supplement was consumed at 10:00 a.m. and 2:00 p.m. --05/15/16 - 50% of the supplement was consumed at 10:00 a.m. and 2:00 p.m. --05/16/16 - 50% of the supplement was consumed at 10:00 a.m. and 2:00 p.m. --05/17/16 - no percentages were recorded. --05/18/16 - she refused the morning supplement and consumed 50% of the 2:00 p.m. supplement. --05/19/16 - she refused the morning supplement and consumed 100% of the 2:00 p.m. supplement. --05/20/16 - she refused the morning supplement and consumed 100% of the 2:00 p.m. supplement. --05/21/16 - 100% of the supplement was consumed at 10:00 a.m. and 2:00 p.m. --05/22/16 - 100% of the supplement was consumed at 10:00 a.m. and 2:00 p.m. --05/23/16 - 100% of the supplement was consumed at 10:00 a.m. and 50% at 2:00 p.m. --05/24/16 - 100% of the supplement was consumed at 10:00 a.m. and 2:00 p.m. --05/25/16 - 100% of the supplement was consumed at 10:00 a.m. and 2:00 p.m. --05/26/16 - 100% of the supplement was consumed at 10:00 a.m. and 2:00 p.m. --05/27/16 - no documentation was provided. --05/28/16 - no documentation of the 10:00 a.m. supplement and the 2:00 p.m. percentage recording is illegible. --05/29/16 - 100% of the supplement was consumed at 10:00 a.m. and 2:00 p.m. --05/30/16 - 100% of the supplement was consumed at 10:00 a.m. and 2:00 p.m. --05/31/16 - 100% of the supplement was consumed at 10:00 a.m. and 2:00 p.m. Of the thirty-four (34) occasions in which the percentages of the house supplement were recorded in (MONTH) of (YEAR), the resident consumed an average of 80.8 % of the supplement. The supplement was provided from 06/01/16 until 06/10/16. The supplement was discontinued on 06/10/16. The percentage of consumption of the house supplement for the ten (10) days of (MONTH) (YEAR) is as follows: --06/01/16 - 50% of the supplement was consumed at 10:00 a.m. and 100 % at 2:00 p.m. --06/02/16 - no documentation was provided. --06/03/16 - 100% was consumed at 10:00 a.m. and 2:00 p.m. --06/04/16 - no documentation was provided. --06/05/16 - 100% was consumed at 10:00 a.m. and 2:00 p.m. --06/06/16 - 100% was consumed at 10:00 a.m. and 2:00 p.m. --06/07/16 - 100% was consumed at 10:00 a.m. and 2:00 p.m. --06/08/16 - 100% was consumed at 10:00 a.m. and 2:00 p.m. --06/09/16 - no documentation was provided. --06/10/16 - 100% was consumed at 10:00 a.m. and 2:00 p.m. Of the fourteen (14) occasions in (MONTH) (YEAR) when the supplement was recorded, the resident consumed 96.4% of the supplement. Interview with the dietary manager (DM) #67 at 8:46 a.m. on 07/07/16, verified the resident was no longer on a house supplement. He said, I am just not sure of what happened, that's not my area. At 8:54 a.m. 07/07/16, the director of nursing (DON) was asked what interventions the facility put into place when the resident had an 18 pound weight loss between 04/04/16 and 05/03/16. The DON stated she would have to look at the resident's medical record. The physician's last progress note, dated 05/27/16, was reviewed with the DON who verified the physician did not address the resident's weight loss. The resident did not receive any screenings by the speech therapist, no appetite stimulants etc. The DON said she did not know why the resident's house supplement was discontinued on 06/10/16. At 9:00 a.m. on 07/07/16, the resident was observed eating breakfast in her room. Nurse Aide (NA) #1 was feeding the resident her breakfast. NA #1 stated, She eats like a bird, but she will drink. The resident was observed taking very small, slow bits of her oatmeal. After approximately five (5) bites of the oatmeal, the resident refused to open her mouth. When NA #1 offered her a carton of milk, the resident readily drank through a straw. At 10:22 a.m. on 07/07/16, the administrator stated the registered dietician was on her way to the facility to discuss the resident's weight loss. At 10:50 a.m. on 07/07/16, the registered dietician (RD), #122, was interviewed. She stated she recommended the supplement be continued on 06/10/16 and wrote a note indicating the supplement should be continued. She reviewed her electronic note, written on 06/10/16, in the medical record. She said, I don't know what happened, the resident would have been reviewed again this week. RD #122 explained supplement orders are written for thirty days. At the end of the 30 days the resident is re-evaluated and if the resident is consuming the supplement, the order is continued. Employee #122 was unaware the resident was not receiving the supplement. RD #122 calculated the resident's weight loss from 04/04/16 to 05/03/16 as a 16.9% weight loss in 30 days. She confirmed the only intervention for the weight loss was the house supplement which had been discontinued on 06/10/16. The daily percentages of the consumption of the house supplement was reviewed with the RD. She agreed the resident was consuming the majority of the supplements which is why she wanted to continue the house supplement. Review of the most recent minimum data set (MDS) with an assessment reference date (ARD) of 04/25/16 noted the resident was on a physician-prescribed weight gain regimen. The resident's MDS also reflected the resident had no swallowing or choking issues, and no loss of liquids/solids from mouth when eating or drinking. The resident's current care plan address the problem of, At nutritional risk with an intervention of house supplements two (2) times a day at 10:00 a.m. and 2:00 p.m. b) Resident #9 Review of Resident #9's medical record at 12:30 p.m. on 07/05/16 found she had been discharged to an acute care hospital a total of six (6) times in the last 12 months. The last discharged took place on 06/22/16. The Director of Nursing (DON) indicated the resident would not be returning to the facility because she passed away while at the hospital. Resident #9's most recent admission prior to her final discharge was on 06/02/16. The resident was readmitted to the facility after an eleven (11) day stay in the hospital which began on 05/22/16. Upon readmission the facility on 06/02/16 the facility obtained the residents weight which was recorded at 100.5 pounds (lbs). Prior to discharge from the facility Resident #9's last recorded weight was obtained on 05/20/16 at which time she weighed 107 lbs. During her hospital stay Resident #9 lost 6.5 lbs. or 6 percent (%) of her body weight. (All percentages of weight loss were calculated using the following formula (usual weight - actual weight)/usual weight X 100 = % of body weight loss.) Registered Dietician (RD) #122 evaluated Resident #9 upon her readmission to the facility on two separate occasions within the first week of her readmission. RD #122 evaluated the resident on 06/03/16 and 06/07/16. On each assessment RD #122 noted the following (typed as written): --Under the heading evaluation and nutritional plan she noted, Readmission review. DX (diagnosis): aspiration PNA (pneumonia) and PEG replaced. NPO (nothing by mouth). Resident triggers for a SWL (Significant weight loss) X 6 months on readmission and wt. (weight) loss trend X 1 and 3 months. BI (body mass index) wnl (within normal limits) Current TF (tube feeding) not meeting est. (estimated) needs. Under the heading Nutrition Interventions LD #122 noted, Rec. (recommend) TF levity 1.5 @ (at) 40 cc (cubic centimeters)/ (per) hr (hour) x (times) 20 hrs (hours) w/ (with) current flushes = 1200 kcal (Kilocalorie), 51 gm (grams) prot. (protein), 600 cc free fluid, 1200 cc w/ flushes. ST (speech therapy ) eval (evaluate) for possible po (by mouth) diet. Please consult RD if po diet ordered. Both assessments indicated the resident BMI was 19.63 and her estimated needs daily were 1,104 calories, 55 grams of protein, and 1,380 cc's of fluid daily. The assessment dated [DATE] indicated that the resident was receiving [MEDICATION NAME] 1.5 at 25 cc's per hour continuously. RD #122 indicated on this assessment that Resident #9 was only receiving 900 calories and 1056 cc's of fluid. Therefore she was not meeting her estimated needs and RD #122 recommended that it be increased to 40 cc's per hour for 20 hours per day on 06/03/16. This recommendation was implemented by facility staff on 06/03/16. The next assessment completed by RD #122 on 06/07/16 indicated the resident at this time was receiving [MEDICATION NAME] 1.5, 40 ccs per hour for 20 hours for a total of 1200 calories and 1200 ccs of fluid. However, her recommendation on this assessment was to have the TF be 40 cc's per hour for 20 hours which Resident #9 was all ready receiving. She also noted in her assessment on 06/07/16 that the TF was not meeting the residents estimated needs. RD #122 did however clarify that statement in a progress note dated 06/22/16, the day Resident #9 was discharged from the facility for the final time. RD #122 indicated in the progress note that there was an error to her assessment dated [DATE] and it should read, TF meeting residents estimated needs. Resident #9 was not assessed by the dietician after 06/07/16. Resident #9 was again weighed on 06/09/16 at which time she weighed 95.2 lbs. She lost an additional 5.3 lbs. or 5 % of her body weight during her first week back at the facility. This represents severe weight loss. There were no additional weights obtained for Resident #9 while at this facility after the weight on 06/09/16. Review of Resident #9's nursing progress notes found a weight warning note dated 06/15/16 which read as follows: Resident was recently readmitted to the facility after an extended hospital stay where she lost a significant amount of weight due to illness. Will monitor for additional changes and notify HCS (health care surrogate) and physician as appropriate. Further review of the record found no evidence the physician and/or the RD was ever notified of Resident #9's additional weight loss of 5% during her first week back in the facility. There was also no evidence in the medical record that nursing ever identified that part of her weight loss occurred after readmission to the facility nor did they intervene to evaluate for further weight loss or to prevent further weight loss. Review of the facility's policy titled Weights and Heights with an effective date of 06/01/01 found all residents are to be weighed upon admission and/or readmission, then weekly for four week and monthly thereafter. The facility failed to implement this policy for Resident #9. She was only weighed on admission then for one (1) week. She was not re-weighed at the conclusion of her second week at the facility and was discharged prior to the conclusion of her third week. Therefore the facility was not able to identify if the resident continued to experience weight loss. The above findings were reviewed with the DON at 3:40 p.m. on 07/05/16. She confirmed Resident #9 had not been weighed weekly per facility policy. She stated that she should have had at least one more weight prior to her discharge on 06/22/16. She indicated that she would have to look to see if they had addressed the weight loss she suffered after readmission to the facility. At the time of exit on 07/07/16 at 2:30 p.m. no additional information was provided. An interview with RD #122 at 10:52 a.m. on 07/07/16 confirmed she had seen the resident on two (2) occasions since her readmission to the facility on [DATE]. She indicated she had not seen or assessed Resident #9 after she lost and additional 5% of her body weight during the first week of her readmission. RD #122 indicated that every week she will print a report which identifies any weight loss and she must have missed Resident #9's on the week of 06/09/16. | 2019-07-01 |