Failure to Provide Timely and Adequate Nutritional Support
Penalty
Summary
The facility failed to initiate timely nutritional interventions for Resident #475, who was admitted with acute failure and other conditions. Upon admission, there was no completed Minimum Data Set, and the resident did not have a feeding order until 20 hours later. Observations revealed that the resident was lying in bed with a feeding tube improperly managed, as it had no cover or cap and was merely clamped off. The resident expressed hunger and discomfort, indicating a lack of adequate nutrition. Staff interviews confirmed that the resident had not received the prescribed nutrition in a timely manner, and there was a delay in obtaining necessary physician orders. Resident #109 was readmitted with severe protein-calorie malnutrition and required Jevity 1.5 formula at a specific rate to meet nutritional needs. However, observations showed discrepancies in the administration of the formula, with significantly less being delivered than ordered. The formula was not running as expected, and the volume administered was far below the prescribed amount. Staff interviews and observations confirmed that the formula was not being administered correctly, leading to inadequate nutritional support for the resident. Both cases highlight the facility's failure to follow physician orders and provide appropriate nutritional care. The lack of timely intervention and adherence to prescribed feeding regimens resulted in residents not receiving the necessary nutrition, potentially impacting their health and recovery. The facility's processes for managing feeding orders and ensuring proper nutrition were inadequate, as evidenced by the observations and staff interviews.
Plan Of Correction
MGMT/RESTORE 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of Resident #475, and the facility not receiving an order for almost 20 hours. Nursing staff will be in-serviced to get and follow doctor's orders in timely fashion as to not delay treatment to the residents. 2) In the instance of Resident #109, not for almost 22 hours and the tube-feeding not running at proper rate. Nursing staff will be in-serviced to get and follow doctor's orders in timely fashion as to not delay treatment to the residents. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: The measures put into place/systemic changes made to ensure the standards are met: Nursing staff will be in-serviced to get and follow doctor's orders in timely fashion as to not delay treatment to the residents. Random QA audits will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: Random QA audit will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. Findings of the QA audits will be reported in the Monthly QAPI meeting by the Director of Nursing or a qualified Designee for a period of three months and until substantial compliance is met. Corrective action completion date: