Inspection Findings:
Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment was completed for residents who had significant changes of condition which included documented findings, resident status, and interventions made as a result of the assessment for 1 of 2 sampled residents (#2) who experienced a significant change of condition in weight status. Findings include, but are not limited to:Resident 2 was admitted to the facility in 12/2021 with diagnoses including dementia and edema.During the acuity interview on 12/06/22, the resident was identified to have a weight change.The resident was observed on 12/06/22 in the dining room for lunch. The resident ate the meal independently and consumed 100 %.Resident 2's weight records were reviewed during the survey and revealed the following:* 01/05/22 - 228.0 pounds;* 06/02/22 - 252.0 pounds;* 08/04/22 - 242.0 pounds; * 11/03/22 - 252.0 pounds; and* 12/01/22 - 232.4 pounds.From 01/2022 to 06/2022, Resident 2 gained 24.0 pounds or 10.52 % of his/her body weight in five months, and from 11/03/22 to 12/01/22, the resident lost 20.6 pounds or 8.51 % of his/her body weight in a month, which represented a significant change of condition.The facility RN completed an assessment on 07/24/22 and stated the "current weight 238 [pounds]" and noted "weight entered on 6/22 is likely data error entry as all other weights are consistent and range for 6 months". However, there was no documented evidence the RN evaluated the resident's weight to support the 06/2022 weight data was an error such as a re-weigh of the resident or obtained the resident's weight in 07/2022.There was no RN assessment for the significant weight loss between 11/2022 and 12/2022 at the time of survey.The need to ensure significant changes of condition were assessed by an RN and the assessment included documentation of findings, the resident's status and interventions made as a result of the assessment was discussed with Staff 1 (Administrator) and Staff 3 (ALF Administrator) on 12/07/22. They acknowledged the findings.
3. Resident 6 was admitted to the facility with diagnoses including dementia, HTN and was on hospice.Resident 6's weight record was reviewed during the survey and revealed the following:* 02/2023 - 148 pounds;* 03/2023 - 140 pounds;* 04/2023 - 133 pounds; and* 05/03/23 - 136 pounds.From 02/2023 to 03/2023, Resident 6 lost 8 pounds or 5.4% of his/her body weight. Between 03/2023 to 04/2023, Resident 6 lost another 7 pounds or 5% of his/her body weight, both of which represented a significant change of condition.There was no documented evidence the RN conducted an assessment of the resident's weight loss from 02/2023 through 04/2023, which included findings, a description of resident status and a plan of care to address the weight loss. Resident 6 was observed eating lunch and snacks independently on 05/15/23 and 05/16/23. S/he ate well when placed with other residents who were eating.On 05/11/23, one month after the second significant weight loss, the new facility RN, Staff 12, completed a significant change of condition assessment for the weight loss and included interventions of encourage resident to eat and drink at meal times, encourage resident to snack during the day and remind of all meals.The requirement to document a timely RN assessment of a resident's significant change of condition was discussed with Staff 1 (Administrator) and Staff 3 (ALF Administrator) on 05/17/23. They acknowledged the findings. No further information was provided.
Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment was completed for residents who had significant changes of condition, which included documented findings, resident status, and interventions made as a result of the assessment for 2 of 2 sampled residents (#s 1 and 6) who experienced a significant change of condition. This is a repeat citation. Findings include, but are not limited to:Resident 1 was admitted to the facility with diagnoses including dementia and Kidney disease (stage III).Resident 1's record was reviewed during the survey and revealed the following:1. The MCC "Weight Report" for Resident 1 documented a monthly gain 26 pounds in 04/2023, and then a loss of 17 pounds in 05/2023.*03/2023 179 pounds;*04/2023 205 (26 pound weight gain); and*05/2023 188 (17 pound weight loss).The significant weight fluctuations between 03/2023 and 04/2023 and also 4/2023 to 5/2023 constituted a significant change of condition.In interview on 05/09/23 Staff 1 (Administrator) stated the weight fluctuation were data errors due to staff using different scales for weights, however, there was no re-weigh, evaluation of the weight data, or referral to the RN for assessment of the weight fluctuation. 2. A progress note dated 04/23/23 noted Resident 1 was found on the floor "holding left shoulder stating it hurts terrible", and "called 911 to have resident evaluated." Resident 1's service plan was updated at return from the emergency room to include the information "returned with a broken left collarbone and large skin tear on left elbow".A 04/24/23 progress note documented "resident struggles with transfers since return from the hospital. Often becomes flustered making ADL unsafe for resident and staff". Also on 04/24/23, a note stated "continue to use PRN acetaminophen (pain medicine) and Risperidone (psychotropic medication) every 6 hours for pain and agitation", and on 04/25/23 "Mobility Change: needing two person assist when getting up from dining room chairs".A "RN post-fall note" dated 04/24/23 failed to document or assess the "large skin tear", fractured bone, unsafe ADL, increased pain and PRN pain medication use, mobility changes requiring two person assist, or to update the service plan with fall interventions.The requirement to document an RN assessment of a resident's significant change of condition that included assessment, findings, resident status, and service plan interventions made as a result of the assessment was discussed with Staff 1 (Administrator) and Staff 3 (ALF Administrator) on 05/17/23. They acknowledged the findings.
Plan of Correction:
OAE 411-054-0045 (1) (a-f) (A) (C-F) Resident health servicesResident 2 has been reassessed for Significant Change of Condition for weight change by the RN. The service plan has been updated to reflect those changes. Memory care manager and RN will review notes, incident reports and alerts daily and will have the assessments and service plan updates completed for all the significant change of conditions within 48 hours. Memory Care Manager will review notes, incident reports, and alerts daily and communicate significant change of conditions to RN. All care staff were re-trained on reporting changes for residents per company policy. RN will have assessment and service plan updates completed for all significant changes of conditions within 48 hours.Service Planning and Significant Change of Condition training was conducted by H&W Director and Corporate RN with the nursing team. All care staff were re-trained on reporting changes for residents per company policy using.Weekly meeting will be held with GM and Health and Wellness team to audit processes. Memory Care Manager will be responsible for overall compliance. C280 - OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health ServicesResident 1 has been assessed by the RN for a significan change of condition for the weight change and a weight monitoring plan of only using the weight chair for weighing not only this resicent but all residents is in place. The service plan has been updated to reflect those changes. Memory care manager and RN will review notes, incident reports and alerts daily and will have the assessments and service plan updates completed for all the significant change of conditions within the 48 hours. Memory Care manager and Resident Care coordinators will review notes, incident reports, and alerts daily and communicte those change of conditions to the RN. All the staff have been re-trained on the process of reporting changes for residents per our company policy. The RN will have all significant change of conditions completed withing 48 hours. Service plan and change of condittion training completed by the H&W director as well as the RN with the nursing team. The staff of the Memory care community were trained on reporting changes for the residents per company policy. Weekly meeting is held for the H&W team, GM to discuss residents of concern and ensure compliance is being met. Memory Care Manager will be responsible for the overall compliance.