HUNTSVILLE, AL- WINDSOR HOUSE

Based on observation, interview, record review and facility policy review, the facility failed to ensure a person-centered, comprehensive care plan was implemented for nine (9) of 37 sampled residents.

Resident #36 experienced a weight loss and care planned interventions were not implemented to address and/or prevent the weight loss from occurring. The MDS revealed Resident #36 required supervision of one (1) staff with bed mobility, transfers, ambulation, locomotion, and eating. The resident required limited assistance of one (1) staff with dressing, toileting, and personal hygiene. The MDS revealed the resident weighed 168 pounds (lbs.), had no swallowing disorders, weight loss or dental problems. The resident did not receive nutritional approaches.
Review of the Care Plan initiated on 9/31/19 and last reviewed on 2/19/21, listed the problem, resident was at risk for altered nutritional status with the intervention to offer alternate meal and snacks when requested, serve diet as ordered and weights per protocol.
Review of the clinical record’s Weight List revealed the following weights in lbs.: 10/14/2020 – 169.9; 11/25/2020 – 157.4; 12/17/2020 – 149.0; 1/18/21 – 137.9; 2/10/21 – 134.0; 3/15/21 – 132.0; 3/22/21 – 129.0; and 3/29/21 – 126.0. This consisted of a 21.13 percent weight loss from 10/14/2020 to 2/10/21 and a 25.84 percent weight loss from 10/14/2020 to 3/29/21.
Review of the physician’s orders [MEDICAL RECORD OR PHYSICIAN ORDER]
Further review of the physician’s orders [MEDICAL RECORD OR PHYSICIAN ORDER]
1/21/21 – Fortified foods with breakfast. (started after the resident lost 32 lbs.)
2/24/21 – Speech Therapy (ST) four (4) times per week times four (4) weeks for oropharyngeal dysphagia, weight loss. (started after the resident lost 35.9 lbs.)
3/1/21 – Med Pass (nutritional supplement) 120 cubic centimeters (cc) two (2) times per day (started after the resident lost 35.9 lbs.)
3/1/21 – Consult Nutrition secondary to weight loss and House Supplements (nutritional supplement) two (2) times a day.
3/24/21 – Continue ST four (4) times per week for four (4) weeks for oropharyngeal dysphagia.
4/7/21 – Unintended weight loss, check weights times four (4) week cycle, check [CONDITION(S)] Stimulating Hormone and Prealbumin level, and discontinue Trazadone (antidepressant) and start Mirtazine (antidepressant and used to stimulate appetite) 15 milligrams (mg) at bedtime.
Review of the clinical record and after request for all Nutritional Assessments and Screenings revealed the facility did not follow the 3/1/21 physician’s orders [MEDICAL RECORD OR PHYSICIAN ORDER]
Review of the Nurse’s Note dated 10/20/2020 at 10:44 p.m. revealed at 3:15 p.m. Resident #36 came to the Nurse and gave him/her their left front tooth implant/bridge, two (2) connected teeth were noted with a post extending from the root of one (1). The resident denied pain and no bleeding noted. The root of the left tooth was visible from the gumline. Will continue plan of care.
Review of Resident #36’s Diet Slip on 4/12/21, revealed the resident received a regular diet with regular texture and received super cereal at breakfast.
Review of the ADL Meal Consumption Record revealed:
On 2/2021 staff did not document meal consumption for 35 of the 84 meals provided.
On 3/2021 staff did not document meal consumption for 36 of the 93 meals provided.
From 4/1/21 to 4/14/21 at 5:00 p.m. staff did not document meal consumption for 26 of the 41 meals provided.

Interview with the MDS Coordinator on 4/14/21 at 3:50 p.m. revealed the care plans were not specific but the Care Guides would be specific and told the staff what interventions were needed for the resident. The MDS Coordinator did not know the facility no longer used the Care Guides.

Interview with the Registered Dietician (RD) on 4/14/21 at 10:04 a.m. revealed the RD assessed the residents within 30 days of admission and then annually. The RD stated he/she reviewed the weights on a weekly basis and as requested by the facility. The RD stated the DM would notify him/her of any changes in the residents. Regarding Resident #36, he/she had a big weight loss towards the end of last year but I believe [he/she] is holding steady. The facility used Med Pass and House Supplement interchangeably and he/she usually recommended 120 cc, but the amount may vary.
Interview with the Director of Nursing (DON) on 4/14/21 at 3:03 p.m. revealed during the morning meetings, Monday through Friday, the Administrator would ask if any residents had a weight loss. For Resident #36, when I documented his/her weights in the computer, the computer was supposed to turn the weight red if there was a significant weight change and it did not. It was a computer error. Resident #36 is a picky eater and ate better without distractions. Resident #36 required assistance with eating and the DON did not know if the resident ate snacks or not. The DON did not know about the resident losing his/her bridge and teeth and did not know if he/she was assessed by a Dentist.