MESA, AZ- MONTECITO POST ACUTE CARE AND REHABILITATION

Honor the resident’s right to and the facility must promote and facilitate resident self-determination through support of resident choice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42319

Based on clinical documentation, resident and staff interviews, and facility policy, the facility failed to ensure preferences regarding meals were honored for one resident (#287). The deficient practice could result in resident’s autonomy not exercised.

Findings include:
Resident #287 was admitted on [DATE] with diagnoses of toxic encephalopathy and protein calorie
malnutrition.

A care plan initiated on August 8, 2023 included the resident had a potential nutritional problem related to diagnoses of protein calorie malnutrition and had increased protein needs related to wound healing due to a pressure ulcer. Interventions included to honor resident rights to make personal dietary choices and provide dietary education as needed.

A nursing note dated August 8, 2023 revealed the resident was alert and oriented x 4.
The mini nutritional assessment dated [DATE] revealed the resident had a score of 10 indicating the resident at risk of malnutrition.

The nutrition admission evaluation dated August 14, 2023 revealed an order for regular diet, texture and consistency. The evaluation included that the resident had a potential for nutritional problem, increased protein needs and had potential for fluid shifts. Recommendation included adding Ensure (supplement) twice daily to meet wound healing needs. The evaluation did not include indication that resident’s dietary preferences were noted.

Review of the clinical record revealed no evidence that the determination of resident’s dietary preferences was completed from August 8 through 15, 2023.

A progress note dated August 16, 2023 included that the dietary manager spoke with the resident regarding food preferences; and that, the resident requested double portions and adding a sandwich with dinner daily. Per the documentation, food preferences were updated and the weekly food menu was filled out.

During an interview with resident #287 conducted on August 15, 2023 at 11:36 a.m., the resident stated he would like bigger portions because he had lost a lot of weight; and, he tried to put his preference on the slip of paper on his meal tray, told the CNAs (certified nurse assistants). However, resident #287 stated that the facility staff had poor communication and his preferences were not carried out.

An interview conducted on August 16, 2023 at 3:27 p.m. the dietary supervisor (staff #123) who stated that when a resident is admitted at the facility dietary staff would get the resident’s diet slip from nursing. She said dietary staff would double check and visits the residents and asks the residents about their dietary preferences. Staff #123 said that resident’s preferences would be entered in the dietary cards within 48 hours of admission. During the interview, a review of the clinical record was conducted with the dietary supervisor who stated that she did not have any notes or dietary preferences recorded for resident #287; and that, she does not know why dietary preferences for resident #287 was not taken and recorded.

An interview was conducted on August 16, 2023 at 5:31 p.m. with a Registered Nurse (RN/staff #55) who said that the kitchen staff comes to the resident and lists the resident’s options and preferences.

An interview was conducted on August 16, 2023 at 5:37 p.m. the unit manager (UM/staff #102) who stated that diet preferences of a resident were normally followed the next day from the day it was known; but, this may not happen over the weekend. He said that if the resident was complaining about their preferences, staff would redo the resident’s assessment to reflect the accurate dietary preferences. Further, the unit manager stated that requests for double portions meals would be done the same way.

In an interview with the Director of Nursing (DON/staff #402) conducted on August 16, 2023 at 5:48 p.m., the DON stated that the expectation was that resident’s dietary preferences should be assessed within 48 to 78 hours of admission. She said that was the process they follow; and that, the resident would also be given a menu to fill out for the whole week. During the interview, a review of the clinical record was conducted with the DON who stated that the clinical record revealed no documentation found on the dietary preferences for resident #287.

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42319

Based on clinical documentation, resident and staff interviews, and facility policy, the facility failed to ensure treatment was administered as ordered by the physician for one resident (#27). The deficient practice could result in resident not receiving care and services based on his assessed needs.

Findings include:
Resident #27 was admitted on [DATE] with diagnoses of spinal stenosis cervical region, spondylosis with myopathy cervical region and functional quadriplegia.

An Admission Minimum Data Set (MDS) assessment dated [DATE] included the resident had moderately cognitive impairment and required extensive assistance one-person physical assistance for most activities of daily living. The assessment also included the resident rejected care 1-3 days during the last 7 days of the look back period.

A care plan dated July 25, 2023 included the resident had an alteration in neurological status related to spinal stenosis and spondylosis, status post repeat spinal surgeries. It also included the resident was a functional quadriplegia and had alteration in musculoskeletal status related to cervical spine fusion.

Intervention included wearing a Miami J collar (neck brace) at all times.

A physician order dated July 25, 2023 included for a C-collar to be worn as ordered by provider.

Despite the order, the clinical record revealed no evidence that the C-collar was documented as
administered as ordered by the physician.

The clinical record also revealed no evidence the resident refused to wear the collar; and that, the physician was notified.

An observation was conducted on August 15, 2023 at 2:21 p.m. revealed resident #27 was sitting up on his bed and was not wearing the C-collar.

In another observation conducted on August 16, 2023 at 4:49 p.m. the resident was in sitting up on his bed and was not wearing a collar. An interview was conducted immediately following the observation. Resident #27 stated that he only needed to wear the C collar when he was not in bed.

An interview was conducted on August 16, 2023 at 5:25 p.m. with a certified nursing assistant (CNA/staff #39) who stated that she thought the RNA (Restorative Nursing Assistant) puts the C-collar on the resident. She said that she sometimes helps but it was usually RNA, the nurse or therapy who puts the C-collar on the resident.

In an interview with a Registered Nurse (RN/staff #55) conducted on August 16, 2023 at 5:27 p.m., the RN stated that resident #27 wears his collar when inside his room and when the resident goes to with therapy, the C-collar was also on. She said that the C-collar had to be removed when the resident was laying down on bed because it was not comfortable. The RN further stated that resident #27 likes to dictate his care and refuses all his medication. However, she stated that the resident’s clinical record revealed no physician order that the C-collar can off when the resident was on bed; and, no documentation that the resident was refusing to wear the C-collar while in bed.

An interview was conducted a unit manager (UM/staff #102) on August 16, 2023 at 5:40 p.m. The unit manager stated that he did not know if it was normal and okay for resident #27 to be in bed without his C-collar on. He stated that if the resident refused to wear it, the refusal should be documented in a progress note. During the interview, a review of the clinical record was conducted the unit manager who stated that he could not find documentation that the resident refused the C-collar and that, the physician was notified.

During an interview with the Director of Nursing (DON/staff #402) conducted on August 16, 2023 at 5:48 p.m., the DON stated when a resident refuse to comply with a physician order, the expectation was for staff to inform the provider, document the refusal, get an order and provide education to the resident. A review of the clinical record was conducted with the DON who stated that the clinical record revealed no documentation of resident refusals and that the physician was notified.

An interview was conducted on August 16, 2023 at 6:00 p.m. with the Director of Rehabilitation (DOR/ staff #19) who stated that she did not know whether the physician was notified that the resident was not wearing the C-collar all the times including when on his bed.

The facility policy on Physician’s orders revealed that it is their policy to accurately implement orders in addition to medication orders (treatment, procedures) only upon the order of a person duly licensed and authorized to do so in accordance with the residents’ plan of care.