Failure to Provide Prescribed Therapeutic Diet
Summary
The facility failed to provide a resident's therapeutic diet as ordered by his physician, placing the resident at risk for complications including choking. The resident, who had diagnoses of dementia and Alzheimer's disease, required a pureed diet with nectar thick liquids due to difficulty or pain with swallowing. Despite this, observations on multiple occasions revealed that the resident was provided with thin liquids instead of the prescribed nectar thick liquids. Staff interviews confirmed that the resident's care plan, which included the dietary order, was accessible in the resident's room and the dining room, and that staff had been educated on the importance of adhering to these dietary orders. On several occasions, thin liquids were observed in the resident's room, contrary to the prescribed nectar thick liquids. Staff members, including a CNA and a licensed nurse, acknowledged the presence of incorrect fluid consistency and indicated that it might have been placed by the night shift. The facility's policy on thickened liquids, revised in March 2020, stated that thickened liquids should be provided as ordered to promote ease of swallowing and prevent choking and aspiration. Despite this policy and staff education, the facility did not consistently adhere to the resident's dietary orders, resulting in a deficiency that placed the resident at risk for serious health complications.
Penalty
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Multiple residents with conditions such as fractures, COPD, dementia, schizophrenia, diabetes, and severe malnutrition, all care-planned for potential nutritional issues and with orders for specific breakfast beverages, did not receive their ordered orange juice or other beverages during a breakfast meal. Dietary tickets and MD orders called for specified amounts of juice and, in one case, coffee, but observations showed these items were missing from trays. Staff later reported that new tray-line employees ran out of orange juice and did not provide an alternate juice, despite facility expectations that residents not on fluid restrictions receive a set amount of juice as part of their daily fluid intake.
A resident with severe cognitive impairment and multiple health conditions, including chronic kidney disease and diuretic use, did not have water maintained at her bedside as required by her care plan. Observations revealed that water was either not present or placed out of the resident's reach, and staff confirmed the resident could not access drinks as needed.
Surveyors found that three residents with significant cognitive and physical impairments did not have water or beverages accessible in their rooms. Staff, including CNAs and an LPN, confirmed the absence of water and only provided it after residents requested it. The facility lacked a policy for providing ice water, contributing to the deficiency in maintaining resident hydration.
Staff did not provide caffeinated coffee or tea to residents, offering only decaffeinated options based on a previous DON's directive, despite residents' stated preferences and no medical reason for restriction. The Medical Director was unaware of any prohibition, and several residents, including the Resident Council President, expressed dissatisfaction with the lack of caffeinated beverages, which was not in line with facility policy to honor resident preferences.
The facility failed to provide adequate hydration between meals, affecting several residents. Observations showed hydration cups were not consistently present in rooms, and residents reported water was not offered unless requested. Staff interviews revealed inconsistencies in water delivery, despite facility policy requiring fresh water each shift. This deficiency impacted residents with specific health risks, as their fluid intake was not recorded as required.
The facility failed to consistently provide ice water to residents, affecting their hydration needs. A resident, who was moderately cognitively impaired and dependent on staff, did not have ice water available in her room. Interviews revealed that inconsistent ice water delivery was a common issue, with some residents not receiving it until after 1:00 P.M. The facility's policy requires fresh ice water to be provided each shift, but this was not adhered to, leading to a deficiency finding.
Failure to Provide Ordered Breakfast Beverages and Honor Resident Preferences
Penalty
Summary
The deficiency involves the facility’s failure to provide beverages according to residents’ diet orders and stated preferences, specifically related to breakfast juice service. Multiple residents had care plans identifying potential for altered nutrition and interventions that included providing diets as ordered and honoring food and beverage preferences. Physician orders and dietary tickets specified that these residents were to receive orange juice or other beverages at breakfast, but observations on the breakfast meal service showed that these ordered beverages were not provided. For one resident with a fracture, muscle weakness, and osteoarthritis, the care plan called for honoring preferences and the physician ordered a regular diet with thin liquids and double entrees, including eight ounces of orange juice at breakfast; the breakfast tray did not include orange juice, and the resident reported that portion sizes, especially at breakfast, were not correct. Another resident with anxiety disorder, schizoaffective disorder, and osteoarthritis, who was dependent on staff for eating, was ordered a regular pureed diet with thin liquids and was supposed to receive orange juice and coffee at breakfast, but neither beverage was on the tray. A resident with anorexia, vascular dementia, and major depressive disorder, whose care plan included nutrient-dense foods and honoring preferences, was ordered a regular diet with fortified cereal and eggs and was supposed to receive orange juice at breakfast, but did not receive it. Additional residents were similarly affected. A resident with multiple sclerosis, COPD, and schizophrenia, who had intact cognition and required supervision for eating, was supposed to receive eight ounces of orange juice at breakfast but did not. A resident with metabolic encephalopathy, diabetes mellitus, and severe protein-calorie malnutrition, whose care plan included nutrient-dense foods and honoring preferences, was supposed to receive four ounces of orange juice at breakfast but did not. Another resident with chronic atrial fibrillation, COPD, and nicotine dependence, with intact cognition and needing supervision for ADLs, was also supposed to receive four ounces of orange juice at breakfast but did not. Staff interviews revealed that two new employees on the tray line ran out of orange juice and did not substitute another type of juice, and facility documentation showed that residents not on fluid restriction were expected to receive four ounces of juice at breakfast as part of their average daily fluid intake.
Failure to Maintain Accessible Hydration for At-Risk Resident
Penalty
Summary
A resident with multiple complex medical conditions, including Alzheimer's disease, dementia, diabetes, chronic kidney disease, and a history of falls, was identified as being at risk for dehydration. Her care plan specifically required that water be maintained at her bedside at all times to support adequate hydration, especially given her use of diuretic medication and potential for fluid imbalance. During an observation, it was noted that the resident did not have any water or beverage available in her room, and there was no evidence of a Styrofoam cup or other drinking vessel as provided to other residents. A CNA confirmed that she had not provided water to the resident that morning and could not locate a cup in the room, suggesting it may have been discarded by housekeeping, although this was not the case in other rooms. On a subsequent observation, the resident was found to have a Styrofoam cup with water, but it was placed on an overbed table near the entry door, out of the resident's reach. Another CNA confirmed that the placement of the table and cup made it inaccessible to the resident, preventing her from obtaining a drink when needed. These findings demonstrate that the facility failed to ensure the resident had water maintained at her bedside and within reach, as required by her care plan.
Failure to Provide Drinking Water to Residents
Penalty
Summary
The facility failed to ensure that residents received drinking water consistent with their needs and preferences, resulting in three out of five observed residents not having water or beverages available to them. One resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease and dysphasia, was observed in bed without water in reach. An LPN confirmed the absence of water and provided it only after the resident requested cold water. Another resident, admitted for surgical aftercare and with significant physical and cognitive impairments, was also found in bed without water accessible. A CNA verified the lack of water, found an empty cup across the room, and provided ice water only after the resident expressed a preference for it. The resident's assigned CNA stated that water is typically passed once a day unless requested. A third resident, with a complex medical history including cerebral infarction, COPD, diabetes, and legal blindness, was observed sitting in a recliner without water or fluids at bedside. The overbed table was dirty and cluttered with food remnants. A CNA confirmed the absence of water or fluids in reach after being prompted by the surveyor. The facility did not have an ice water policy in place at the time of the survey. These observations and staff interviews demonstrate a failure to provide adequate hydration opportunities for residents as required.
Failure to Provide Drinks Consistent with Resident Preferences
Penalty
Summary
The facility failed to honor residents' drink preferences by not providing caffeinated coffee or tea, despite residents' requests and the absence of medical contraindications. Interviews with dietary staff revealed that residents were only offered decaffeinated beverages, based on a previous directive from the former DON, and staff believed caffeinated drinks were not allowed due to their stimulant properties. The Medical Director was unaware of any restriction on caffeinated coffee and confirmed there was no known medical reason to prohibit it. Residents expressed dissatisfaction, stating they preferred regular coffee and were told it was not available due to budget constraints or concerns about medication interactions. The facility's policy requires that residents be provided with drinks consistent with their needs and preferences, but this was not followed. The deficiency had the potential to affect all residents except for two who were NPO. The Resident Council President and other residents confirmed that they were recently informed of the restriction on caffeinated beverages, and many disliked the decaffeinated alternatives. The facility census at the time was 70.
Inadequate Hydration Practices in Facility
Penalty
Summary
The facility failed to ensure adequate hydration was provided between meals, affecting four residents and potentially impacting 41 others who received food from the kitchen. Residents #121 and #122, both cognitively intact, reported that water was not consistently provided between meals unless requested. Observations confirmed that hydration cups were not consistently present in resident rooms, and the facility's policy required State Tested Nurse Aides (STNAs) to provide fresh ice water to residents each shift, which was not adhered to. Resident #121, who has chronic respiratory failure and other health issues, was at risk for dehydration due to obesity and diuretic use. Her care plan included monitoring for dehydration signs, but there was no evidence of fluid intake being recorded in her medical records for the past 30 days. Similarly, Resident #122, with conditions like congestive heart failure and moderate protein-calorie malnutrition, had no recorded fluid intake in her medical records, despite her care plan requiring meal intake, including fluids, to be recorded. Interviews with staff, including CNAs and LPNs, revealed inconsistencies in water delivery practices. Some staff were unsure of the frequency of water passing, while others confirmed that water was supposed to be provided each shift but was not consistently done. The facility's policy, revised in 2018, mandated that fresh water be delivered each shift and upon request, but this was not consistently implemented, leading to the deficiency noted in the report.
Inconsistent Ice Water Delivery to Residents
Penalty
Summary
The facility failed to ensure that residents received ice water in their rooms as per their preferences and needs, which is essential for maintaining hydration. This deficiency was identified through observations, interviews, and record reviews. Specifically, Resident #3, who was moderately cognitively impaired and dependent on staff for activities of daily living, did not have ice water available in her room during an observation. The resident expressed a desire to have ice water, indicating a lapse in the facility's hydration practices. Interviews with an ombudsman and another resident revealed that the issue of inconsistent ice water delivery was a common concern among residents. The Assistant Director of Nursing confirmed receiving complaints from both staff and residents about the irregular provision of ice water, sometimes not being delivered until after 1:00 P.M. The facility's policy, dated November 2018, mandates that State-tested Nursing Assistants provide fresh ice water to residents each shift, with additional deliveries as needed. This deficiency was investigated under Complaint Number OH00158883.
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