Soldiers and Sailors Memorial Hospital Extended Care Unit
Deficiency Details, Certification Survey, June 10, 2011
Regional Office: WRO--Rochester Area Office
F325 483.25(i): RESIDENT MAINTAIN NUTRITIONAL STATUS UNLESS UNAVOIDABLE
Severity: Potential for more than Minimal Harm
Corrected Date: August 9, 2011
Based on a resident's comprehensive assessment, the facility must ensure that a resident - (1) Maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible; and (2) Receives a therapeutic diet when there is a nutritional problem.
Citation date: June 10, 2011
Based on observations, staff interviews, and record reviews, the facility did not ensure that a resident maintained acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrated that this was not possible and receives a therapeutic diet when there is a nutritional problem. Two (Residents #1, and #2) of six residents reviewed for nutrition had concerns that were identified with lack of intake monitoring and lack of revisions to the nutritional plan of care to prevent weight loss. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:
1. Resident #1 has diagnoses including dementia. Review of the 5/6/11 Minimum Data Set (MDS) Assessment revealed that the resident has severely impaired cognition, significant weight loss, a Stage II pressure ulcer, and requires limited assistance of one person to physically assist with eating.
Review of the Plan of Care for nutritional status, initiated 3/12/07, revealed that the resident is at nutritional risk. Interventions included a No Added Salt diet, nutritional supplements, to monitor intakes, and to revise meal plan as indicated. The weight goal was established as 125pounds (lbs.), + or - 5 lbs.
Review of the resident's Weight Chart revealed the following weights: 11/10, 126.5 lbs.; 12/10, 122.5 lbs.; 1/11, 118.2 lbs.; 2/11, 110.04 lbs., re-weight, 118.04 lbs.; 3/11, 119.04 lbs.; 4/11, 117.96 lbs.; and 5/11, 114 lbs.
Review of the Progress Record, dated 11/24/10 through 2/11/11, lacked documented evidence that the resident's weight and intakes were evaluated or that meal plan changes were implemented.
Review of the 2/11/11 Nutrition Quarterly Review revealed that the resident weighed 118.04 lbs. and had experienced a 7 percent significant weight loss in three months, consumed 59 percent of meals, and received a No Added Salt diet with health shakes at breakfast and supper, cranberry juice at lunch, a banana for morning, and canned fruit for afternoon supplements. The weight goal remained 125 lbs, + or - 5 lbs. Review of the 2/11/11 Nutrition Progress note, written by the Registered Dietitian (RD), revealed that a health shake would be added at lunch and she would follow-up.
The Plan of Care for nutritional status included a handwritten entry, dated 3/10/11, for a sippy cup for all drinks. Review of the Progress Record, dated 2/11/11 through 5/4/11 revealed no documented evidence that the resident's weights and intakes were evaluated or any further changes were implemented.
Review of the 5/4/11 Nutrition Quarterly Review and Nutrition Progress Note revealed that the resident weighed 114 lbs., had 11 percent significant weight loss in six months, has an open area to the sacrum, consumed 17 percent of meals, and received a No Added Salt diet with health shakes three times a day with meals, cranberry juice at lunch, and no between meal supplements. The RD documented that a health shake would be added as an afternoon nourishment to help prevent further weight loss. The weight goal was changed to 115 lbs. + or - 5 lbs. There was no further documentation by the RD.
Review of the Snack/Nourishment Checklist by Unit sheets, dated 5/4/11 through 6/8/11, revealed that the resident was not included to receive afternoon nourishment.
On 6/8/11 at 12:15 p.m., the resident was observed during the lunch meal. The resident's meal tray included 2 percent milk, Health shake and cranberry juice, and the entree with No Added Salt. At 12:55 p.m., the resident had consumed bites and sips of the meal.
When observed on 6/9/11 at 8:30 a.m., the resident was finished with breakfast and had consumed bites of scrambled egg, approximately half of her cereal and drinks that included 2 percent milk and a Health shake.
When interviewed on 6/9/11 at 9:15 a..m. and 9:45 a.m., the RD said that she analyzes weights monthly for significant weight loss. She said she did not change the resident's meal plan after 11/24/10 until the resident had significant weight loss on 2/11/11. She said she would not necessarily make any changes to the nutritional Plan of Care if a resident lost "a few pounds" in a month but said that if she had made changes earlier, the significant weight loss may have been prevented. The RD said that there was more that could have been done to boost the resident's intakes, such as providing whole or chocolate milk at meals and trying different snack items. She said she did not know why the resident was on a No Added Salt diet but that liberalizing the No Added Salt diet would also be a possible intervention. The RD also said that she tries to review the Snack/Nourishment Checklists every week to monitor snack acceptance for need to make changes. She said that the Snack/Nourishment Checklists are printed two weeks ahead of time and do not reflect any snacks that are added until the next set of printed sheets come out. She added that she would not know if a resident was receiving the planned nourishment, or how they were accepting it, until it showed up on the sheets. She was sure that the resident was receiving the afternoon health shake. When observed with the RD at this time, the snack tray for 6/9/11 did not include an afternoon health shake for the resident. The RD said that it must have gotten missed.
When interviewed on 6/9/11 at 11:30 a.m. and 6/10/11 at 9:15 a.m., the Corporate RD said that she expects that the Snack/Nourishment Checklists are monitored by the RD weekly to see if changes need to be made. She said that printing the sheets every two weeks can cause things to be missed and that their process for monitoring snack consumption needs to be changed to help catch any problems. She also said that there was more that could have been done for the resident, such as an intake study, weekly weights, liberalization of her diet and meal plan changes, that may have prevented the significant weight loss.
Review of the 6/11/11 weight record revealed the resident weighed 110 lbs., showing a further 3.5 percent weight loss in the past month.
2. Resident #2 has diagnoses including severe dementia, diabetes mellitus, peripheral vascular disease, and a non-healing ulcer of the right foot.
Review of the Plan of Care for Nutritional Status, initiated 5/4/10, revealed that the resident was at nutritional risk and included approaches to monitor weight and intakes and revise meal plan as indicated. The goal was to maintain the resident's weight between 115 lbs. + or - 5 lbs.
Review of the resident's weight chart revealed the following weights: 11/10, 124 lbs.; 12/10, 122 lbs.; 1/11, 119 lbs.; 2/11, 114 lbs.; 3/11, 113.5 lbs.; 4/11, 108 lbs.; and, 5/11, 105 lbs. Weights were discontinued on 6/8/11.
Review of the 5/27/11 MDS Assessment revealed that the resident has severely impaired cognition.
Review of Nutrition Progress Notes, dated 4/20/11 and 4/22/11, revealed that the resident weighed 104 lbs. and had significant weight loss. A three-day intake study done at this time revealed that the resident was meeting 58 percent of her estimated calorie needs, 91 percent of estimated protein needs, and 72 percent of estimated fluid needs. On 4/22/11 a Magic Cup ice cream was added for morning and afternoon nourishments. Review of a 4/27/11 Nutrition Progress Note, written by the RD revealed that the resident's morning nourishment would be changed from magic cup to Glucerna to see if the resident will accept liquids better than solids. The RD documented that she would monitor intake of nourishments for acceptance. Review of a 4/29/11 Nutrition Progress Note revealed that the resident was on a cardiac, low sodium, low fat, low cholesterol diet.
Review of Nutrition Progress Notes, dated 5/6/11 and 5/19/11, and the Nutrition Quarterly review, dated 5/23/11, revealed that the resident's weight was 105 lbs. and that the diet was liberalized to a regular diet. Neither the Nutrition Progress notes nor the Quarterly review included an evaluation of the resident's nourishment acceptance or any changes in the meal or nourishment plan.
Review of the Nourishment Checklist by Unit sheets, dated 4/27/11 through 5/6/11, revealed that the resident was not included to receive a morning and afternoon nourishment, except for handwritten entries as follows: 5/1/11, resident drank all of the 8-ounce Glucerna; 5/2/11, 8-ounce Ensure Plus was delivered; and 5/5/11, resident took sips of the 8-ounce Glucerna. Review of the Nourishment Checklist by Unit sheets, dated 5/6/11 through 6/8/11, revealed that the resident was to receive an 8-ounce Glucerna at morning nourishment. Documentation of percent consumed revealed that 15 of 31 days were not filled in, and on 9 of 31 days, the resident consumed less than 25 percent. The sheets showed that the resident was to receive Magic Cup ice cream at the afternoon nourishment, and 11 of 31 days were not filled in. On 8 of 31 days, the resident consumed bites or refused the ice cream.
When interviewed on 6/9/11 at 9:15 a.m. and 9:45 a.m., the RD said that she was not aware of the resident's nourishment acceptance since 4/22/11 and that after reviewing the sheets with the surveyor, she would be changing the nourishments due to poor acceptance.
[10 NYCRR 415.12 (i)(1)]
F156 483.10(b)(5) - (10), 483.10(b)(1): INFORM RESIDENT OF SERVICES/CHARGES/LEGAL RIGHTS/ETC.
Severity: Potential for no more than Minimal Harm
Corrected Date: August 9, 2011
The facility must inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. The facility must also provide the resident with the notice (if any) of the State developed under ¾1919(e)(6) of the Act. Such notification must be made prior to or upon admission and during the resident's stay. Receipt of such information, and any amendments to it, must be acknowledged in writing. The facility must inform each resident who is entitled to Medicaid benefits, in writing, at the time of admission to the nursing facility or, when the resident becomes eligible for Medicaid of the items and services that are included in nursing facility services under the State plan and for which the resident may not be charged; those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and inform each resident when changes are made to the items and services specified in paragraphs (5)(i)(A) and (B) of this section. The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare or by the facility's per diem rate. The facility must furnish a written description of legal rights which includes: A description of the manner of protecting personal funds, under paragraph (c) of this section; A description of the requirements and procedures for establishing eligibility for Medicaid, including the right to request an assessment under section 1924(c) which determines the extent of a couple's non-exempt resources at the time of institutionalization and attributes to the community spouse an equitable share of resources which cannot be considered available for payment toward the cost of the institutionalized spouse's medical care in his or her process of spending down to Medicaid eligibility levels. A posting of names, addresses, and telephone numbers of all pertinent State client advocacy groups such as the State survey and certification agency, the State licensure office, the State ombudsman program, the protection and advocacy network, and the Medicaid fraud control unit; and a statement that the resident may file a complaint with the State survey and certification agency concerning resident abuse, neglect, and misappropriation of resident property in the facility, and non-compliance with the advance directives requirements. The facility must comply with the requirements specified in subpart I of part 489 of this chapter related to maintaining written policies and procedures regarding advance directives. These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the individual's option, formulate an advance directive. This includes a written description of the facility's policies to implement advance directives and applicable State law. The facility must inform each resident of the name, specialty, and way of contacting the physician responsible for his or her care. The facility must prominently display in the facility written information, and provide to residents and applicants for admission oral and written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits.
Citation date: June 10, 2011
Based on record review and staff interviews, it was determined that for two of two records reviewed for Liability Notices and Beneficiary Appeals Rights (Demand Bills), the facility did not suspend billing while waiting for the decision from the fiscal intermediary. This affected Residents #23 and #27, resulting in a pattern of no actual harm with potential for minimal harm, and is evidenced by the following:
1. Resident #27 was admitted on 2/26/11 and given a denial of Medicare services letter on admission. A Demand Bill was requested and sent to Medicare/Fiscal Intermediary on 2/26/11. A bill was sent to the resident/family on 4/12/11, and the facility was paid $9,216.80 on 5/18/11. The facility received the Medicare decision on 5/31/11.
2. Resident #23 was admitted on 2/27/11 and given a denial of Medicare services letter on admission. A Demand Bill was requested and sent to Medicare/Fiscal Intermediary on 3/1/11. A bill was sent to the resident/family on 3/3/11 and $595.72 was paid on 3/4/11. The facility received the Medicare decision regarding the Demand Bill on 5/17/11.
In an interview on 6/9/11 at 1:45 p.m., the Patient Account Team Leader stated that she was aware that they were not supposed to bill the resident/family if a Demand Bill was pending, but she did it because the family of Resident #27 requested the bill. She went on to say that for Resident #23, a new biller sent the bill and probably was not aware of the regulation prohibiting the facility to bill pending a Demand Bill decision. In an interview at this time, the Administrator said that she was aware of this regulation.
[10 NYCRR 415.3(g)(2)(i)]