Putnam Nursing & Rehabilitation Center

Based on observation, staff interviews and record review, the facility did not consistently maintain acceptable parameters of nutritional status in that the facility did not consistently monitor nor implement planned measures to address a significant weight loss. This was evident for one resident in a sample of 14 residents reviewed for weight and nutrition. (Resident # 10)

This resulted in actual harm that is not immediate jeopardy.

Finding is:

Resident #10 was admitted to the facility on 5/23/06 with diagnoses including Anxiety Disorder, Depression, and Parkinson's Disease.
A review of the 3/21/11 care plan reveals the resident is at risk for unplanned loss in body weight; her Ideal Body Weight is 110-120 pounds; and she is on a No Added Salt regular diet. She is assisted with meals by 1 staff member.

Review of the facility's monthly weight record for this resident revealed a weight loss from 128 pounds in the first week of July, 2011 to 98 pounds on August 12, 2011. This represents a 30 pound weight loss.

Review of the Dietitian's "Nutrition Assessment" dated 8/13/11 documents a "significant change due to weight loss." The resident's ideal body weight range as per this assessment is documented as 115 pounds plus or minus 10 percent. The Dietitian further indicates on this document, "fair intake noted on 3 day meal observation." In addition, she documents that this weight loss will be brought to the Weight Committee. There is no documented evidence that this weight loss was ever brought to that committee. At this time, the resident's supplement Health Shakes with meals (which the dietician ordered on 7/1/11) was changed to Magic Cups (a frozen nutritional supplement) ordered by the Dietitian to be given with meals as the resident was not consistently taking the Health Shakes.

Review of the dietician's " Meal Round Audit Sheets" for July and August , 2011 revealed the resident consumed Health Shakes fair to poor. Review of the facility "Meal Consumption Records" dated July, 2011 through August, 2011 revealed an area for staff to document intake of each nourishment/supplement provided. Review of this document for Resident #10 revealed that there was no documentation to substantiate that this resident had received either Health Shakes or Magic cups throughout July and August, 2011.

On 8/31/11 at 12:45PM, Resident #10 was observed at lunch by the surveyor to have a reduced calorie sorbet on her meal tray. The resident was observed to eat only 50% of her sandwich and 100% of the reduced calorie sorbet. The meal tray ticket did not indicate that the resident was supposed to receive any supplement, including the Magic Cup.

Interview with the RN (Registered Nurse) Clinical Care Coordinator at this time stated that the resident was supposed to receive a high calorie Magic Cup, not the reduced calorie sorbet that she received and consumed. She promptly notified the Dietitian of this error.

When interviewed at 12:55PM on 8/31/11, the Dietitian stated that the kitchen did not send the correct nutritional supplement to this resident.

Review of the weight records reveals:
June, 2011-119 pounds
July , 2011, week 1 - 128 pounds
reweigh 7/9 - 116.4 pounds
7/16 -106 pounds
7/23 - 107 pounds
August 12, 2011 - 98.2 pounds

The Dietitian was interviewed on 8/31/11 3:00PM and on 9/1/11 at 10:00AM. During this interview with regard to the significant weight loss, the Dietitian stated that she did not believe the weights documented on the weight sheets may not be accurate as residents may be weighed using different scales.

In an interview with the Director of Nursing (DNS) on 9/1/11 at 12:30PM, she stated that the nurses aides do weight the residents on the correct scales as indicated on all the resident weight records. Further interview with the DNS at this time in regard to Resident #10's weight loss revealed that the Dietitian had not made Nursing aware of the significant weight loss. She further confirmed that nursing staff had not documented that any nutritional supplement had been given to Resident #10 through July and August, 2011.

The RN MDS Coordinator was asked to provide the MDS (a standard assessment) completed by the facility with regard to the Significant Change in weight documented by the Dietitian. When questioned on 9/1/11 at 12:00PM, she stated that there was no significant change MDS completed as she was not aware of the weight loss.

The resident's current weight as last recorded on the Treatment Administration Record on 8/26/11 was 101 pounds.

415.12(i)(1)

Based on interviews and record reviews, the facility did not consistently follow professional standards of nursing practice for physician's orders for two residents. 1) Resident #5 has a foley catheter and orders for two "as needed" pain medications. There was inconsistent documentation of output; and no parameters ordered to assist nurses in determining which of two "as needed" pain medications to offer. 2) Resident #9 who is ordered to have nothing by mouth, has orders for two medications to be administered by mouth. This was evident for two of 24 residents sampled for physician's orders. (Resident # 5 and #9)

This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

Findings are:

1. Resident #5 was admitted to the facility on 4/27/11 with diagnoses including Chronic airway obstruction, Rheumatoid Arthritis, and Pressure Sores.

Review of the resident's physician's orders dated August, 2011 revealed that this resident has physician's orders for Tylenol, 650 mg. (a non-narcotic analgesic) to be administered every four hours, as needed, for pain. The resident also has an order for Dilaudid, 4 mg ( a narcotic analgesic) to be administered every four hours for pain. The orders do not provide parameters to assist licensed nurses in determining when to administer which pain medication.

During an interview with the Director of Nursing (DON) on 8/30/11 at 2:00PM, she stated that the orders for pain medication should be clarified.

Review of Resident #5's Treatment Administration Record (TAR) dated August, 2011 revealed that licensed nurses were to be recording this resident's output (amount of urine voided) from her foley catheter each shift. As of 8/29/11, there were 97 opportunities to document output, however, nurses had only documented 9 times from August 1 through August 29, 2011.

During an interview with the DON on September 1, 2011 at 1:00pm, she concurred that nurses should have documented the resident's output each shift during this time period.

2. Resident #9 was admitted to the facility on 12/5/8 with diagnosis including Anoxic Brain Injury, Dysphagia and Dementia. Review of the resident's physician's orders dated August, 2011 reveal that the resident is to receive nothing by mouth and is fed by gastrostomy tube. Further review of these orders reveal; an order for Tylenol (a non-narcotic analgesic) to be administered, as needed, by mouth, as well as Milk of Magnesia to be administered, as needed by mouth.

During an interview with the DON on 9/1/11 at 10:00am, she stated that the orders were in error and that despite the by mouth orders, nurses have consistently administered these medication via the gastrostomy tube, if needed.

415.11(c)(3)(i)

Based on observation and interview it was determined that all doors in smoke barriers did not have at least a 20 minute fire protection rating and were not self-closing or automatic-closing. This situation could impact on the effectiveness of horizontal evacuation if needed during a fire emergency.

This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

On 8/31/11 at approximately 11:30 AM the smoke barriers on the 3rd floor were evaluated. It was determined that at one location, the intervening bathroom between rooms 328 & 326 circumvented the smoke barrier. Both doors to this bathroom were hollow core, 'luan' type doors and were not of fire resistive construction. In addition, neither of the two doors to this bathroom were self closing. This situation was also noted on the 2nd floor between rooms 226 & 228. One of the two doors into these intervening bathrooms must be a self-closing door having at least a 20-minute fire protection rating.

In an interview at the time, the Director of Maintenance indicated that the doors had not been replaced.

NFPA 101, 2000 - 19.2.2.2.6,19.3.7.6
711.2(a)(1)

Based on observation and interview it was determined that all control valves effecting the sprinkler system were not electronically supervised to warn when the valve is closed. This condition could not ensure that the sprinkler system is maintained in proper operating condition at all times.

This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

On 8/31/11 at approximately 11:00 AM the water main entering the building was inspected. It was noted that this water main splits into the domestic supply and the sprinkler system. The water main was provided with a shut off valve before the point at which the domestic and sprinkler systems separate. The Director of Maintenance stated at the time that closure of this control valve would shut down the sprinkler system. This control valve was neither chained nor electronically supervised to warn that the valve was closed. All other control valves for the sprinkler system were properly supervised.

NFPA 101 2000 - 9.7.2.1
711.2(a)(1)