**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** REPEAT DEFICIENCY C # NJ166425 Based on interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to prevent, identify and address an unintended insidious (gradual but with harmful effects) weight loss of 9.4 pounds in less than a two-month period (4/10/23 to 6/5/23) in a timely manner for a resident who was identified as underweight, with inadequate intake and at nutritional risk on admission. The facility failed to: a.) obtain, record and monitor weekly weights for 4 weeks after admission, and b.) implement a nutritional care plan in a timely manner. This deficient practice was identified for 1 of 2 resident's reviewed for nutrition (Resident #358). The evidence was as follows: The surveyor reviewed the medical record for Resident # 358. Review of the resident's admission Record (an admission summary) reflected the resident was admitted with diagnoses that included but were not limited to; type two diabetes, hypertension, chronic lymphocytic leukemia, and oropharyngeal dysphagia (difficulty swallowing). Review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 4/17/23, reflected a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated the resident's cognition was moderately impaired. It further reflected that the resident required extensive assistance of one person for the task of eating. In addition, it reflected that the resident had an active diagnosis of malnutrition or was at risk for malnutrition and received a mechanically altered diet. Review of the Care Area Assessment (CAA) Summary reflected the decision to care plan for nutritional status. Review of the Physician's Orders (POs) from both the electronic medical record (EMR) and the paper chart for April, May, and June of 2023, included a diet order dated 4/10/23 for 2 gm [gram] sodium dysphagia puree texture, nectar consistency [for liquids], which was advanced to a diet dated 5/26/23, Regular diet Dysphagia Advanced texture [ground], Thin consistency [for liquids], no salt packet. In addition, there was a PO dated 4/12/23 for Resident is At Risk for Malnutrition (Refer to dietitian and/or MD [physician] documentation. There was also a PO dated 6/9/23 for a four ounce (oz) shake two times a day which would provide 400 calories and 12 grams of protein. Upon further review, there was a PO for Full code . CPR to be administered. There was no PO to obtain weights for Resident #358. Review of the April, May, and June 2023 electronic Medication Administration Record (eMAR) and electronic Treatment Administration Record (eTAR) did not include documented evidence that weights were obtained and recorded for Resident #358. In addition, the June eMAR reflected that the four-ounce nutritional supplement was consumed by the resident twice a day from 6/12/23 through 6/20/23. The surveyor reviewed the weight record in the EMR. Weights documented were as follows: 4/10/23: 130.4 pounds (lbs.) Review of the Registered Dietitian's (RD) #1 admission Nutritional Evaluation V2 dated 4/11/23, reflected that the resident was 130.4 lbs. on admission. The RD identified the residents BMI (body mass index: a screening method to determine weight status as underweight, healthy weight, overweight or obese) as 19.8 low for age. The RD did not obtain the residents usual body weight or food preferences or dislikes. The RD identified that the resident required assistance at meals. The RD further documented that the resident would need to consume 75 percent (%) of meals to meet his/her estimated nutritional needs yet in summary documented that the resident consumed 50-60% of his/her meals. The RD documented that the resident had a low body weight . BMI .consistent with underweight . current intake appears inadequate to meet [his/her] needs . [he/she] is at nutritional risk for pressure ulcers and malnutrition due to underweight. She further documented to liberalize the diet by removing the low sodium component, however added no other interventions that would supplement calories. RD #1 documented to evaluate weights, labs, intake, hydration and .proceed with care plan. Review of RD #1's Nutrition Concern: Follow up note dated 6/9/23, included the following weights: (4/10) 130.4 lbs., (5/8) 126.2 lbs., (5/24) 122.2 lbs., (6/5) 121 lbs. The RD documented the weights reflected a 5.2 lbs. / 4.12% weight loss in one month and a 9.4 lbs. / 7.2% weight loss in two months. She acknowledged that the resident had not received supplementation yet received preferred foods twice a day (there was no documented evidence of preferred foods). RD #1 documented that the resident experienced unfavorable weight loss due to inadequate intake. She further documented that she observed the resident only consume 25% of lunch that day. At this time the RD documented that she would start the resident on a shake twice a day, fortified cereal and pudding with meals, would continue to monitor the resident's weight and would start meal monitoring x 3 days start (6/12/23) for better evaluation of intake. Review of the EMR and paper chart did not reveal documented evidence that meal monitoring was conducted or evaluated. In addition, there was no other RD documentation. Review of the EMR and paper chart did not reveal documented evidence that physician services were aware of the resident's weight losses. In addition, review of the EMR and paper chart did not reveal documented evidence of edema or fluid concerns. Review of the EMR Progress notes reflected IDCP (interdisciplinary care plan) team meeting's dated 6/12/23 and 6/19/23, which did not include the resident's weight status. In addition, there was an IDCP meeting note dated 6/8/23, which reflected the team met with the resident's daughter to discuss discharge plans. There was no documented evidence that the residents weight losses were discussed with the resident's daughter. Further review of the progress notes included a Health status note dated 6/20/23, reflected that the resident's daughter discharged the resident AMA (against medical advice). Review of the resident's Care Plan initiated on 4/10/23, included a nutrition care plan which was created on 5/8/23 (28 days after admission) by the RD. The focus area included that the resident had suboptimal intake and a BMI of 19.8. It did not reflect the resident's 4.2 lbs. weight loss since admission as was reflected in the RD note dated 6/9/23. The RD's goals for the resident reflected to maintain adequate nutritional status as evidenced by maintaining weight within 130 lbs. plus or minus 3 lbs., no signs or symptoms of malnutrition, and consuming at least 60% of at least three meals . The RD's interventions included RD to evaluate and make diet change recommendations PRN [as needed] and Weigh per facility protocol. The care plan did not reflect the resident's actual status on 5/8/23 nor was it updated as the resident's status changed to reflect a decline in weight, intake and nutritional interventions as indicated in the RD's 6/9/23 progress note. On 1/18/24 at 1:20 PM, the surveyor interviewed the Registered Nurse (RN) for the [NAME] unit where Resident #358 resided. She stated that the Certified Nurse Aides (CNA) obtained weights which the nurse recorded in the EMR. The RN stated that the weights are initially recorded on paper but once entered into the EMR the paper documentation was shredded. She stated that if a resident required weekly weights there should be a PO. She stated that it was facility policy to obtain an admission weight and then weekly weights for four (4) weeks when a resident was newly admitted . She stated that the weights should be recorded in the weights and vitals section and/or in the eMAR or eTAR section of the EMR. The RN further stated that residents were weighed weekly if they experienced a significant or unplanned weight loss. She stated that the RD reviewed the weights and would notify the physician if there was a weight loss. In addition, the RN stated that if a resident experienced an unplanned weight loss, she would expect the RD to request a reweight to verify the weight, implement and review weekly weights, reassess the resident's nutritional needs and put interventions into place. She stated that she would expect the RD to document this and communicate the same to the nursing staff team. The RN stated that she would expect the CNA and RD to monitor the resident's meal intake and that the RD would intervene timely. On 1/23/24 at 10:16 AM, the surveyor interviewed RD #2. She stated that CNAs obtained weights and they are recorded in the weights and vitals section of the EMR. She stated that if a resident experienced an unplanned weight loss, she would implement weekly weights for further monitoring. She stated that newly admitted residents were weighed on admission and then weekly for four (4) weeks after. The RD stated that weekly weights were monitored by the team which included the CNA, the nurse and the RD. She stated that the RD would oversee the process and monitor the weekly weights. The RD stated that she would review hospital records as part of the nutritional assessment process. She stated that if a resident had an unplanned weight loss, she would have requested a reweight to verify the weight loss, assess the resident's intake, update food preferences and if there was no improvement, she would implement weekly weights and notify the physician. The RD stated that if a resident was assessed to have suboptimal intake on admission, she would liberalize the diet and if the resident experienced weight loss she would add fortified foods and/or health shakes. She added that if that did not abate the weight loss she would continue to reassess and change interventions. The surveyor reviewed the EMR for Resident #358 with RD #2. She acknowledged the surveyors' concerns. On 1/23/24 at 11:25 AM, the surveyor interviewed RD #2 who stated that RD #1's initial intervention to liberalize the resident's diet was appropriate. She acknowledged that weekly weights were not done per facility policy. At this time, she acknowledged that RD #1's progress note dated 6/9/23 identified unplanned weight losses and that was the first-time supplementation was addressed. On 1/23/24 at 12:04 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON) and the Regional Infection Preventionist (RIP) to discuss concerns related to Resident #358. On 1/23/24 at 12:49 PM, the DON and RIP acknowledged that weights should have been obtained and recorded initially on admission and for weekly for the next four weeks. They stated that the RD should have addressed the resident's unplanned weight loss. The LNHA stated and acknowledged that was too long for the RD to wait to reassess and implement interventions. The LNHA, DON and RIP acknowledged that based on RD #1's 6/9/23 note, the RD had knowledge of the resident's weight losses on 5/8/23, 5/24/23 and 6/5/23 and did not intervene timely. The RIP acknowledged that since the RD identified Resident #358 at nutritional risk on admission, and with a low BMI, the RD should have intervened from admission and should not have just liberalized diet which did not provide additional calories. On 1/24/24 10:09 AM, the surveyor interviewed the MDS coordinator (MDSC) in the presence of the survey team. She stated that care plans should be implemented on admission and if there are any problems or changes it should be updated immediately. She stated that if a resident experienced a weight loss a care plan should be implemented. The MDSC stated that the facility conducted monthly weight meetings which the RD, DON, herself and the clinical team attended. She stated that the RD or nurse would update the care plan, the family and physician would be called, and weekly weights and supplements would be implemented. She stated that if a CAA was triggered for an MDS that would indicate an area of concern which should be care planned. She further stated that this should have been discussed at the resident's care plan meeting. Review of the EMR for Resident #358, the MDSC acknowledged that the resident's initial care plan meeting was held on 4/21/23, and the RD did not attend. She stated all disciplines should attend the initial care plan. The MDSC acknowledged that the RD #1's initial evaluation was completed on 4/11/23, the nutrition care plan was initiated on 5/8/23, and a follow up nutrition note was not done until 6/9/23. She stated baseline care plans should be initiated on admission and the comprehensive care plan needed to be completed 21 days after admission. On 1/24/24 at 10:55 AM, the surveyor interviewed RD #3 in the presence of the survey team. She stated that the facility conducted weight meetings but could not speak to documentation. She stated she was not sure if this would have been documented in the EMR. She stated that if she identified that a resident had a weight loss, she would obtain a reweight to verify the weight loss and would assess for possible causes. RD #3 stated she would add interventions to the care plan which would have included weekly weights and supplements. In addition, she stated that she would have discussed concerns and interventions with the team, the Unit Manager and the physician. RD #3 stated she would have documented in the EMR as well. She stated this would be her process whether a resident had a significant weight loss or an unplanned insidious weight loss. On 1/24/24 at 11:22 AM, the survey team met with the LNHA, DON, RIP and the Regional Nurse. At that time, the RIP acknowledged that prior to July 2023, there were concerns related to missing weights for new admissions and weight loss. Review of the facility policy Weight Monitoring dated 8/2023, included the following: - Based on the resident's comprehensive assessment, the facility will ensure that all resident's maintain acceptable parameters of nutritional status, such as usual body weight . - Weight can be a useful indicator of nutritional status. Significant unintended changes in weight .or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem . Suggested weight schedule: Newly admitted residents - weekly for 4 weeks. - Significant weight change is defined as 5% within one month, 7.5% within three months and 10% within six months. It also included that the physician should be notified and who may order nutritional interventions. - The physician should be encouraged to document a diagnosis or clinical condition that could have contributed to the weight loss. - Meal consumption may be recorded for the team to reference and the RD should be consulted to assist with interventions and actions should be recorded in the nutrition progress notes. Review of the policy provided by the facility Medical Nutrition Therapy: Assessment and Care Planning dated 9/2017, included the following: - The RD is responsible for the completion of a comprehensive nutrition assessment for all residents for the purpose of identifying and planning nutrition care based on the needs, goals, and preferences of each resident. - The RD contributes to the comprehensive care plan within 21 days of admission and reviews/revises the plan of care as indicted by the clinical condition of the resident. - The RD recommendations will be communicated via the summary recommendation sheet. - The RD will be responsible for ensuring the plan of care for each resident is in concert with the residents expressed wished for care and services. Review of the undated facility policy Fortified Food Program, included the following: - The goal of the fortified food program is to be able to provide higher calorie and/or higher protein food items to a resident if the intake of regular foods or beverages are not able to meet estimated nutritional needs. - These are nutrient dense items and do not increase food volume. - Fortified food program may be used for nutritional rehabilitation. - . if the intake of regular and/or fortified foods becomes limited, a commercial supplement can be offered in between meals to help increase overall calorie and protein intake. Review of the facility policy Clinical practice: Therapeutic Snacks and Nutritional Supplements dated 7/2016, included the following: - Food preference interviews with the resident, resident's family, or through observation should be completed for all residents. - Nutrition interventions should be discussed with the resident or resident's family. - Inadequate intake may be related to medical, functional, and psychosocial factors associated with the resident's condition. A root cause analysis must be completed to identify the causative factors that will direct the plan of care. - Between meal snacks can contribute to an increase in total nutrient intake. - An indication to modify a resident's meal plan included insufficient intake through meals and an evening snack evidenced by unintended weight loss (significant and insidious). - The resident's care plan should be updated to include additional food items. - Indications for use of supplements include a resident's inability to consume adequately through meals and snacks. - The nutrition plan of care is developed through the RAI [Resident Assessment Instrument] process: MDS, CAA's, and assessment to develop the plan of care. Review of the signed job description for RD #1 titled Registered Dietitian dated 4/3/23, included the following: - Responsibilities include planning, organizing, developing and directing the nutritional care of the resident in accordance with current federal, state, and local standards, guidelines, and regulations that govern the facility. - Completes comprehensive nutrition assessments, including MDS, CAA, assessment, and care plan development, in accordance with federal and state regulatory guidance. - Consults with resident's, family, or interdisciplinary team as needed regarding the plan of care for residents. - Participates in care plan and quality assurance committee meeting as needed, including weight and wound meetings. NJAC 8:39 - 11.2(d)(e)(1)(f), 17.1(c), 17.2(d), 27.1(a)