**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview, and record review the facility failed to ensure residents received care and services to maintain acceptable parameters of nutritional status and there was a safe and accurate system to prevent complications from enteral (feedings administered through a tube) feedings for 12 of 12 residents (Residents 8, 19, 20, 22, 33, 21, 18, 26, 24, 14, 31 & 40) reviewed for nutrition and hydration. The failure to: accurately assess (and re-assess as needed) residents nutritional status and develop/revise/implement person-centered care plans (CP) for residents at risk; reconcile, accurately transcribe, and implement nutrition related physician orders and/or Registered Dietician (RD) recommendations; ensure timely RD evaluations; ensure residents were weighed according to policy/physician orders and monitored routinely; and ensure residents who required downgraded texture diets received the diet they were ordered and speech evaluations (Residents 14 & 24); and ensure residents who required fluid restrictions were monitored/documented accurately (Resident 31). These failures placed residents at risk for weight loss, electrolyte imbalances, dehydration, aspiration, pneumonia, and hospitalization and constituted an Immediate Jeopardy (IJ).
Resident 20 experienced harm when they required urgent transfer to the hospital on [DATE] and was admitted with a diagnoses with aspiration pneumonia, sepsis, severe dehydration, severe malnutrition, and acute kidney injury after the facility failed to: accurately assess and develop/revise a CP to ensure aspiration precautions were followed to help prevent aspiration pneumonia; monitor, document, and evaluate their nutritional status and intake to insure they received the nutrition/fluids they required to meet their daily needs to prevent avoidable dehydration and severe malnutrition; ensure licensed staff routinely provided physician ordered oral care to help prevent infection in the event of aspiration.
Resident 22 experienced harm when they required repeated transfers to the emergency room and hospitalized for dehydration and uncontrolled blood sugars after the facility failed to: accurately assess their feeding tube status and develop CP interventions to prevent dehydration and fluid volume loss; were not provided the nutrition they were ordered to receive, and delayed implementation of physician orders for interventions to correct their electrolyte imbalance.
Resident 40 experienced harm when they had an unplanned significant weight loss of 20 pounds in two weeks. The facility failed to develop and implement a person-centered nutrition CP that addressed their identified risks and care needs, consistently monitor weights, or evaluate oral intake for a resident identified at risk for altered nutrition.
An Immediate Jeopardy (IJ) was called on 02/26/2025 at 2:45 PM in CFR 483.25(g)(1)-(3) when the facility failed to have a safe and accurate system in place for residents receiving nutrition enterally to maintain acceptable parameters of nutritional and hydration status. This failure caused harm to three residents and placed residents at risk for severe weight loss, significant dehydration, aspiration, and death. The immediacy was removed on 02/27/2025 after onsite verification by the investigator reviewed the facility's nutrition related documentation, nutrition assessments, staff education, facility audits, and accurate implementation of provider orders.
Findings included .
<POLICY>
Review of the facility's Enteral Nutrition policy, revised November 2018, showed staff would provide adequate nutritional support via tube feeding as ordered by the physician. The nurse would confirm the tube feeding orders were complete including: the correct formula, the specific enteral access device (gastric tube or jejunostomy tube, etc.), the administration method (continuous, bolus, or intermittent), the volume/rate/time of administration, the volume/rate goals with advancement recommendations, and flushing (solution, volume, frequently, timing, and 24-hour volume). The provider would consider need for lab orders, head of bed elevation, oral care, and checks for gastric residual volume. Risk of aspiration (which was affected by was affected by moderate to severe swallowing difficulties, improper positioning of the resident during feeding, and failure to confirm placement prior to initiating feeding) would be assessed by the nurse and provider and addressed in the residents' care plan. The nursing staff and the provider would monitor the resident for signs or symptoms of inadequate nutrition, altered hydration, high or low blood sugars, altered electrolytes (such as sodium and potassium levels in the blood), and for worsening conditions that placed the resident at risk for nutrition/hydration complications.
<RESIDENT 20>
Review of the 02/16/2025 Quarterly MDS showed Resident 20 admitted to the facility on [DATE], had severe problems with cognition, and diagnoses included pneumonia, dysphagia, chronic obstructive pulmonary disease (restrictive airway), presence of a feeding tube, and was at risk for malnutrition. Resident 20's weight measured 127 pounds and was not assessed to have significant weight changes.
Review of Resident 20's speech evaluation, dated 11/20/2024, showed Resident 20 had severe dysphagia and history of aspiration pneumonia. Resident 20 had asthma and a very weak cough that was not effective to clear aspirated materials when they were cued to cough. They were determined to require nothing passed orally (NPO) status with long-term assisted nutrition (tube feeding) as their new established baseline. The speech pathologist documented they were not able to treat further and placed a sign in their room regarding STRICT NPO status and recommended frequent oral care.
Review of Resident 20's Nutrition Hydration risk CP, revised 01/08/2025, showed the CP interventions were not person-centered and did not include timeframes and parameters for monitoring to achieve desired nutritional goals including how often they should be weighed.
Review of Resident 20's Feeding Tube CP, initiated 01/08/2025, directed staff to ensure their HOB was elevated at least 30-45 degrees during tube feeding and for 30 minutes after, NPO, and provide good oral care (with no frequency directives or how it was supposed to be provided). The task was assigned to both the NACs and Nurses.
Review of Resident 20's February 2025 MAR/TARs showed:
-A physician order dated 01/28/2025 for tube feeding formula at 70 ml/hr for 20 hours (total volume 1400 ml/day), on at 2:00 PM and off at 10:00 AM. Based on the order, the facility should have provided 560 ml on the Day shift and 840 ml on the night shift. The documentation showed 24-hour total volumes administered were: 02/01/2025 (560ml), 02/02/2025 (560 ml), 02/03/2025 (560 ml), 02/04/2025 (1120 ml), 1680 ml each day 02/05/2025, 02/06/2025, 02/07/2025, 02/08/2025, and 02/09/2025.
-A physician order dated 01/09/2025 for tube feeding water hydration water flush of 49ml/hour x 20 hours while the tube feeding formula was running (to total 273-410ml/shift). The documentation was set up for three eight-hour shifts per day unlike the formula documentation that was set up for two 12-hour shifts per day. The total volume in the text of the order did not show accurate shift total volume goals. Based on the order, Resident 20 should have been provided: 196 ml of water on the day shift, 392 ml on the evening shift, and 392 ml on the night shift for a total 24-hour volume of 980 ml/day. The documentation showed the 24-hour total water volumes administered were: 450ml (530ml less than they required) on 02/01/2025, 02/02/2025, 02/3/2025, 02/4/2025, 02/05/2025, and 02/08/2025; 300 ml (680ml less than required) on 02/06/2025, 542ml (438ml less than required) on 02/07//2025, and 934 ml (46ml less than required) on 02/09/2025.
-A physician order dated 12/11/2024 directed staff to provide oral care with prescribed oral solution and an oral swab and HOB greater than 60 degrees and suction PRN (as needed). The documentation showed that oral care was never provided.
CHANGE OF CONDITION:
Review of a Medication Administration Note, dated 02/09/2025 at 2:41 PM, showed to keep HOB at least 30 degrees while tube feeding is running. When it is not elevated properly, resident starts a gurgling sound in their throat. Have stressed importance to staff and resident to keep HOB elevated at all times.
Review of a Medication Administration Note, dated 02/10/2025 at 4:52 AM, showed they administered Tylenol for a temperature of 99.6 and Resident 20 had shallow respirations.
Review of Resident 20's Kardex, dated 02/10/2025, showed under Alerts/Safety: staff to provide local care to feeding tube site as ordered and monitor for signs or symptoms of infection task for licensed nurses only, not CNAs. The Kardex did not show any directions to staff they were STRICT NPO, had HOB requirements for elevation of 30-45 degrees during tube feeding (or at-all-times), who was responsible for oral care and when, complications/symptoms to monitor for and when to notify the nurse, foley catheter care, or documentation of urine output.
Review of an eINTERACT Situation/Background/Assessment/Recommendation (SBAR) Summary for Providers change of condition note, dated 02/10/2025 at 6:07 AM, showed Resident 20 experienced a change of condition related to fever. The documentation showed their vital signs (timed for 7:13 AM) were a very low blood pressure (79/56), Heart rate was very high (138), respirations were very high (28), oxygen saturation was very low at 82% with oxygen on a nasal cannula, and temperature was elevated at 99.8 degrees. The physical assessment showed they had labored and rapid breathing with abnormal lung sounds and a resting pulse greater than 100 beats per minute. The Nursing observations, evaluation, and recommendations showed Resident 20 was transferred out to the hospital after they developed fever, shallow breathing and hyperventilation (breathing too fast). The writer contacted the on-call provider who gave an order for oxygen at two liters per minute, a breathing treatment, and to monitor vital signs every 30 minutes until stable then change to every two hours. They administered Tylenol but it was not effective. The documentation did not indicate what time the actual change was identified, what time the provider was contacted, the exact time of the interventions implemented (and resident response), and what time they were transferred out of the facility.
Review of a hospital inpatient progress note, dated 02/11/2025, showed Resident 20 was admitted with septic shock (severe infection) and acute hypoxic respiratory failure due to aspiration pneumonia, hypernatremia (dehydration), acute kidney injury, and severe malnutrition.
readmission:
Review of the Kardex, dated 02/25/2025, showed it had not been updated after readmission.
Review of the February 2025 MAR/TARs showed:
-A physician order dated 02/13/2025 for tube feeding formula at 70 ml/hour x 20 hours (total volume 1400 ml/day). The documentation for 24-hour shift totals showed: 840 ml on 02/14/2025 and 560ml each day from 02/15/2025 to 02/20/2025.
-A physician order dated 02/13/2025 for FWF (free water flush) at 41 ml/hour x 20 hours to provide total volume of 820 ml. The documentation did not show shift volumes administered or total 24-hour volumes.
In an observation on 03/03/2025 at 3:55 PM, Resident 20 was in bed, the tube feeding was disconnected as ordered. No suction machine was observed at the bedside. Their HOB was at 15 degrees. There was one oral swab in the top drawer of the nightstand. Resident 20 was not interviewable due to their cognition although they appeared awake and alert. Resident 20 opened their mouth for an observation, their lips and oral cavity appeared dry and unclean.
<RESIDENT 22>
Review of Resident 22's Quarterly MDS, dated [DATE] showed they had severe problems with cognition, dependent on staff for all ADL cares, and diagnoses included a stroke with hemiplegia (unable to move a side of the body), diabetes, high blood pressure, heart failure, and was not at risk for malnutrition. Resident 22 weighed 149 pounds and did not receive tube feeding.
Review of Resident 22's Nutrition Hydration Status risk CP, initiated 01/09/2025 showed Resident 22 had a feeding tube, was NPO, and history of ER visits due to clogged feeding tube. The 01/09/2025 CP interventions included: Aspiration precautions, directions to follow orders for diet and labs, and observe for signs or symptoms of dehydration (i.e., dry mouth, cracked lips, dry skin, and decreased urine output). The CP did not include person-centered goals/interventions for maintaining a patent feeding tube or parameters for monitoring of nutritional status.
Review of the Tube Feeding CP, revised 01/09/2025, showed Resident 22's HOB requirement was to be at least 30-45 degrees during tube feeding and for 30 minutes after the tube feeding, provide/maintain good oral hygiene (but did not specify how often and who performed it) and nursing was to record Resident 22's formula intake and water flushes on the MAR/TARs. The CP did not include person-centered interventions to meet all their identified care needs.
Review of a nurse progress note, dated 01/17/2025 at 1:48 PM, showed Resident 22 was sent to the emergency room because their feeding tube was clogged, and they were unable to remove the blockage. The resident required ambulance transport to the hospital to have their feeding tube replaced.
PHYSICIAN ORDERS:
Review of Resident 22's January 2025 MAR/TAR showed:
-A physician order dated 01/09/2025, for Diabetisource 1.2 at 78 ml/hour for 20 hours, on at 4:00 PM and off at 12:00 PM (total volume 1560 ml). The order set for documentation showed administration times for 12:00 AM and 12:00 PM. Between 01/10/2025 at 12:00 AM and 01/28/2025 at 12:00 AM, there was no documentation the tube feeding was administered, the boxes were blank for 18 days.
-A physician's order, dated 01/09/2025 for feeding tube water flushes 28 ml/hour for 20 hours from 4:00 PM to 12:00 PM (total volume 280 ml per shift) but the total volume shift goal in the text of the order was transcribed incorrectly, did not equal what 28ml/hour for 20 hours would provide (560 ml), and the documentation showed they were administered 280 ml each shift (3 shifts).
-A physician's order dated 09/29/2023 for weekly weights and the TAR documentation showed no weights were measured for 01/06/2025, 01/13/2025 and 01/20/2025. Resident 22's weight on 01/27/2025 measured 149 pounds.
CHANGE OF CONDITION & DELAYED CARE:
Review of Resident 22's blood sugar record from 02/01/2025 to 02/13/2025 showed they began having very high blood sugars.
Review of providers progress note, dated 02/12/2025, showed Resident 22's blood pressure at 3:51 PM was 116/67 and heart rate was elevated (102). The documentation showed they reviewed Resident 22's abnormal labs including a very high sodium level (dehydration is the most common cause for high sodium levels) and very high blood sugars. On 02/12/2025 at 6:00 AM the physician ordered one liter of intravenous fluids and then repeat the labs. This was the first ordered intervention to correct the critical sodium level, 30 hours after the Lab Company notified the facility of the critical lab value on 02/10/2025 at 11:37 PM.
Review of a nurse progress note, dated 02/12/2025 at 11:45 AM, showed the facility did not have the fluids the provider ordered (a special type of solution used to correct this high sodium level) and the pharmacy would not be able to deliver any for four hours.
Review of a nurse progress note, dated 02/12/2025 at 3:40 PM, showed they started intravenous administration of the ordered fluids at 3:30 PM, (39 hours after they were notified of the critical lab value).
Review of the nurse progress note, dated 02/13/2025 at 3:47 AM, showed the Lab Company called the facility and reported the repeat sodium level was higher than the sodium result sodium result on 02/10/2025. The nurse called the on-call provider who ordered Resident 22 be transferred to the hospital.
readmission:
Review of the Hospital Post Acute & Transition of Care Orders, dated 02/17/2025, showed n tube feeding orders for Diabetisource AC at 65 ml/hour x 24 hours and water flushes of 150ml every four hours. Resident 22 was diagnosed with a high sodium level, high blood sugar and fluid volume deficet (needed 5.7 liters).
Review of the Resident 22's February 2025 MAR of the orders transcribed on readmission showed:
-The tube feeding order, dated 02/17/2025, was Diabetisource 1.2 at 78 ml/hour x 20 hours on at 4pm and off at 12:00 PM (total volume 1560ml/day), the same tube feeding order they had before they went to the hospital for dehydration and uncontrolled blood sugars, and no volume totals documented.
-The Water flush order, dated 02/17/2025, for 50ml/hour x 20 hours from 4:00 pm to 12:00 PM (total of 1000 ml/day), and no total volumes documented.
-The order for the lab to monitor the potassium was not transcribed to the admission orders and was not drawn two to three days after admission.
During an observation on 02/24/2025 at 12:00 PM, Resident 22 was awake in bed, their tube feeding was running, and the HOB did not appear to be at least 30 degrees or more. Resident 22's lips were dry, very chapped, with large pieces of dry, dead skin hanging off their lips. Their teeth appeared to have a film of debris covering them.
-At 12:02 PM, Staff CC, LPN, entered the room with a small medicine cup of clear liquid and did not appear to notice the HOB was not at 30 degrees. At 12:03 PM, Staff CC was asked what the HOB elevation requirements were for Resident 22. Staff CC stated the HOB was to be at 30-45 degrees during tube feeding and at least 30 minutes after the tube feeding was stopped, which they were there to do. Staff CC was asked if the HOB was at 30 degrees, and they stated yes. Staff CC was asked how they knew it was 30 degrees; they looked at the bed for a few seconds, stated just a minute, then left the room without stopping the tube feeding.
-At 12:05 PM, a CNA entered the room with a meal tray for Resident 22's roommate, realized the roommate was not in the room, and then left the room (with the meal tray) but did not recognize Resident 22's HOB was not elevated to 30 degrees while the tube feeding was running.
-At 12:08 PM, Staff N, CNA, entered the room with personal care items for Resident 22. Staff N was asked about the HOB requirements for Resident 22 and replied, 30 to 45 degrees at all times. Staff N was asked if they thought Resident 22's HOB was at least 30 degrees, and Staff N stated, definitely not. Staff N stated they last cared for Resident 22 about 10:30 AM and they always double check the HOB level before they left the room. Staff N stated when they needed to provide cares for Resident 22, they notified the nurse so they could put the tube feeding on hold to perform cares safely, and either the nurse was their care partner, and if not, they notified the nurse when their tasks were completed.
-At 12:10 PM, Staff CC returned to the room with an angle gauge. When Staff CC applied the angle gauge to the bed, they found the angle gauge that was already on the bed, hidden under the mattress cover. Staff CC confirmed the HOB was not at 30 degrees and stopped the tube feeing. Staff N stated they didn't know about the gauge on the bed but thought it was a good idea.
-Observation at 12:10 PM of the angle gauge on Resident 22's bed showed the angle of the HOB was at 20 degrees. Staff CC was unsure how long it had been less than 30 degrees.
-At 12:12 PM, Staff CC began providing Resident 22 oral care and stated the nurses provided the oral care every shift. Staff CC stated they were also there to check Resident 22's blood sugar which was ordered for before meals and at bedtime and then they would disconnect his tube feeding and clear the pump. Staff CC stated the total volumes on the pump showed the previous nurses did not clear the pump on their shift.
In an interview on 02/25/2025 at 3:30PM, Staff H, LPN-RCM, stated they were not aware the tube feeding orders were changed at the hospital.
In an interview on 02/26/2025 at 10:47 AM, Staff O stated they were not aware of the hospital provider ordered Diabetisource AC but if they had, they would have recommended to proceed with that product due to its carbohydrate nutritional properties which show better blood sugar control.
<RESIDENT 40>
Review of Resident 40's hospital After Visit Summary dated 12/16/2024 showed their weight measured 133 pounds.
Review of the 12/22/2024 admission MDS showed Resident 40 admitted to the facility on [DATE], had severe cognition problems, required assistance with ADLs, and diagnoses included a respiratory infection, diabetes, dementia, hypokalemia (low amount of potassium in the blood). Resident 40 was not at risk for malnutrition and weighed 135 pounds. Resident 40 had no natural teeth.
Review of Resident 40's nutrition CP, initiated 12/16/2024, showed they were at risk for nutritional/fluid deficits due to preferences not to eat or drink. The interventions provided were not person-centered and did not address the risk factors identified in the comprehensive assessment. The CP directed staff to monitor/document/report to MD PRN for signs or symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals. The CP did not indicate how often Resident 40 should be weighed, monitor intake and record every meal. RD to evaluate and make diet change recommendations as needed.
Review of Resident 40's Kardex, dated 12/18/2024, showed CNAs were informed they were able to eat with supervision but did not provide instructions regarding their diet order, dental status, or when to report to the nurse if they did not consume a certain percent of their meal/fluids for each meal.
A physician's order, dated 12/18/2024, directed staff to weight Resident 40 on 12/16/2024, 12/17/2024, 12/18/2024 then weekly for three weeks. Review of the weight record showed their weight measured 135 pounds on 12/17/2024, 12/18/2024, and 12/20/2024.
Review of the Nutrition Evaluation, dated 12/26/2024, showed Resident 40's weight was stable and their estimated calorie needs were 1230-1500 kcal per day and 1800 ml of fluid/day. The RD recommended to provide one diabetic meal replacement supplement for additional calories and protein and continue weekly weights. The CP was not updated.
Review of Resident 40's weight record showed no weight measurement for 12/27/2024. On 01/03/2025, their weight measured 115 pounds, a 14.8% weight loss in two weeks.
Review of Resident 40's progress notes, between 01/02/2025 and 01/10/2025, showed no documented nurse progress notes or skilled charting documentation. There was no documentation to show the facility identified Resident 40's significant weight loss on 01/03/2025, or that the physician and responsible party were notified of the weight loss. The progress notes did not indicate Resident 40 was on alert charting status, did not provide consistent monitoring of their intake, or evaluation for increased need of assistance for eating.
In a physician's note, dated 01/10/2025 (untimed), showed Resident 40 had increased confusion and was difficult to arouse. Their physical exam showed Resident 40 had fluid volume deficit.
Review of a physician's order, dated 01/10/2025 at 12:28 PM, showed instructions to start intravenous (IV) fluids for rehydration at 75 ml/hour for three days (no number of liters were given) to start at 5:00 PM. The order was confirmed by a nurse at 12:30 PM.
Review of the January 2025 MAR showed the 01/10/2025 physician order for IV fluids due at 5:00 PM. The documentation showed 9-other/see nurse notes.
Review of the nurse progress showed no nurse progress notes for 1/10/2025 after 2:44 AM when a late entry daily skilled note was entered. The nurse progress notes did not provide documentation to show Resident 40 was ordered IV fluids, why the fluids were not initiated, or Resident 40's change of condition status.
Review of a physician's order, dated 01/11/2025 at 12:04 PM, showed to place a peripheral IV for hydration (19 hours after the IV was ordered to start) and a second order to administer IV rehydration at 75 ml/hour for three days.
Review of the Peripheral IV Insertion Record, dated 01/11/2025 at 12:30 PM, showed a traveling IV Nurse started an IV access in the left arm.
Review of the January 2025 MAR/TAR showed the 01/11/2025 order for IV rehydration. The documentation did not show the volume of fluids administered for each shift to indicate how much fluid Resident 40 received.
Review of Resident 40's fluid intake documentation between 01/09/2025 and 01/15/2025 only showed their fluid intake from meals. On 01/10/2025 their fluid intake from all meals was 920 ml and on 01/11/2025 it was 500 ml.
Review of Resident 40's Weight Summary Report dated 01/10/2025 showed they had a greater than 10% weight loss in less than 180 days.
Review of the Nutrition Hydration Skin Committee Review evaluation dated 01/14/2025 showed Resident 40's weight measured 119 pounds. The documentation showed they only had a 5% unplanned significant weight loss, consumed 25-50% of their meals, and had abnormal labs that showed fluid volume deficit and required IV hydration to correct. They planned to increase Resident 40's diabetic meal replacement supplement to two times a day. The documentation did not show the IDT evaluated Resident 40 to identify why they lost the weight. The CP was not updated.
In an interview on 03/19/2025 at 12:45 PM, Resident 40's Responsible Party, RP, stated they not notified of Resident 40's weight loss in the beginning of January but could tell they had lost a lot of weight. RP did not know it was 20 pounds. RP stated on 01/10/2025, the physician said they would start IV fluids because Resident 40 was dehydrated. RP stated [they] came back the next day around lunch time and Resident 40's IV fluids were still sitting at the bedside, and they did not have an IV-line in. They found out the IV had not been started because no one could start IVs. RP stated the facility finally called in a nurse to start the IV on 01/11/2025. RP stated Resident 40 was missing their bottom denture since admission.
<RESIDENT 8>
Review of the 12/31/2024 admission Minimum Data Set (MDS), an assessment tool, showed Resident 8 admitted to the facility on [DATE], had mild cognition problems, required assistance with activities of daily living, and diagnoses included a stroke, dysphagia (impaired swallowing), diabetes, and a newly placed feeding tube. Resident 8 was not at risk for malnutrition, weighed 202 pounds, received more than half of their total calorie needs for the week from tube feeding but only received a total of 500 ml's or less for average daily fluid intake for the week.
Review of Resident 8's Nutrition Hydration Status CP, dated 12/25/2024, showed they were on aspiration precautions, directed staff to monitor for signs or symptoms of dehydration, and was referred to the RD for evaluation of their nutritional status. The 12/25/2024 intervention for diet order stated, per MD order and was not personalized to show they were NPO (nothing by mouth). The CP did not provide personalized interventions and timeframes/parameters for monitoring.
The Comprehensive CP, initiated 12/25/2024, did not show a focus problem for feeding tube status, maintenance, and care. The CP did not show interventions for HOB elevation requirements to prevent aspiration or oral care frequency, who was responsible for oral care, and how it was to be performed.
Review of Resident 8's Kardex (care plan directives to the direct care staff- Certified Nursing Assistants -CNAs), dated 12/25/2024, 12/26/2024, and 12/31/2024, showed the same interventions that included bathing preferences, floating heels while in bed, and leisure activities. The Kardex did not show that Resident 8 was NPO status, their tube feeding schedule, HOB elevation requirements, aspiration precautions, oral care responsibilities, or complications/signs/symptoms to monitor for and report.
Review of Resident 8's Kardex, dated 01/06/2026 (12 days after admission), showed tasks for feeding tube site care and water flushing per physician orders (duties for licensed staff only). The Kardex did not show interventions for HOB elevation requirements, aspiration precautions, tube feeding complications to monitor for, oral care interventions, or urinary catheter care.
In an interview on 02/24/2025 at 12:15 PM, Staff M, CNA, stated they knew the residents who were NPO or who had other special care needs through communication during shift report and by reviewing the Kardex in their POC (Point-of-care electronic documentation system). Staff M stated they were expected to review the Kardex daily to identify changes in the resident's CP that were specific to their job duties. Staff M confirmed that if the Kardex did not have the necessary information to meet the resident's basic care need it was difficult to care for the residents and made some cares more time consuming.
In an interview on 03/03/2025 at 12:15 PM, Staff C, Registered Nurse-RN/Resident Care Manager-RCM, stated it was the responsibility of the admitting nurse to initiate the baseline care plan and the Kardex for the direct care staff to meet their basic care needs after admission. It was their expectation it was done by the end of the shift they arrived on or at least by the end of the day. Staff C stated the Interdisciplinary Team (IDT) reviewed new admissions during their clinical meeting and the RCMs were responsible to complete the CPs and other tasks that were incomplete or needed correction.
PHYSICIAN ORDERS:
Review of Resident 8's Hospital Provider Orders-Nursing Home Transfer, dated 12/25/2024, showed Resident 8's diet was NPO and the tube feeding orders showed Glucerna 1.2 (supplemental nutrition) at 25 milliliters (ml)/hr (hour) now and advance by 15 ml every six hours until goal rate of 85ml/hour, x 16 hours per day and additional water flush of 30 ml every four hours, and monitor intake/output. Resident 8's weight measured 225 pounds.
Review of the December 2024 Medication and Treatment Administration Records (MAR/TAR) showed:
-A physician's order dated 12/25/2024, Glucerna 1.2 @ 70 ml/hr x 16 hours/day and increase the rate to 85ml/hour in six hours. The tube feeding order was not complete with all required components according to their facility policy. The order was never discontinued and a new order transcribed to show they increased the rate to 85ml/hour six hours after admission on [DATE]. The MAR/TARs did not provide documentation to show the total volume of formula administered each shift or the 24-hour totals. The documentation showed the rate of administration was at 70ml/hour (15ml/hour less than ordered) from 12/26/2025 until the order was discontinued on 01/06/2025.
-A physician's order dated 12/25/2024, for water flushes: 15-30 ml of water before and after medication administrations. The TARs did not show total volume of water provided each shift for all medications administered.
-The MAR/TARs did not show the physician's order, dated 12/25/2024, for water hydration flushes of 30ml every four hours (total 180ml/day) was transcribed or implemented by staff.
In an interview on 02/24/2025 at 4:00 PM, Staff G, Licensed Practical Nurse-LPN/ RCM, stated the MAR/TAR did not include the 12/25/2024 order for water hydration and could not state if it was implemented. Staff G stated the MAR/TAR did not show they increased the formu[TRUNCATED]