Alta Skilled Nursing: 71-Pound Weight Loss Unmonitored - NV

Resident 143 weighed 200 pounds when he was readmitted in April 2024 after treatment for a bleeding ulcer. By May 9, he weighed just 129 pounds — a 35.5% weight loss that qualified as severe malnutrition under the facility's own policy.

The resident had three separate physician orders for weekly weighing. The first, dated April 6, called for weekly weights for four weeks. An April 11 order specified weights "every day shift, every Thursday, for 30 days." A third order on April 20 again required weekly weights for four weeks.

Staff weighed him exactly twice during this period.

The resident told inspectors on June 10 that he "did not feel like eating most of the time and thought there was weight loss." The next day, he couldn't recall when the facility had last weighed him.

Director of Nursing confirmed there was "only one weight in the resident's clinical record since admission and there should have been at least four weights for the weekly weights." The facility's registered dietician acknowledged using the hospital's 200-pound weight as baseline "rather than an actual physical weight performed by the facility."

A May 15 weight committee meeting documented the "drastic/questionable 71 lbs. weight loss in one month" and recommended weekly weights "for close monitoring." Those weekly weights never happened.

The facility's Weight Assessment and Intervention policy required residents to be weighed on admission, the next day, and weekly for two weeks. Any weight loss of 5% or more in one month was considered significant. Greater than 5% was classified as severe.

Another resident hadn't been weighed in over six months despite facility policy requiring monthly weighing for all residents.

Resident 37, admitted in 2019 with diabetes and dementia, was last weighed on November 27, 2023. His weight report showed no measurements between November 28, 2023, and June 11, 2024 — a gap of more than six months.

The registered dietician confirmed the resident "had not been weighed in over six months and should have been weighed monthly per the facility policy." The Director of Nursing said it was "important to ensure residents were weighed one time per month in order to assess for weight loss, weight gain, and to determine if there was a change in dietary needs, or medications."

Medication shortages left residents without critical treatments for days. Resident 18, who suffers from chronic pancreatitis and muscle spasms, ran out of both prescribed medications in May 2024.

The resident told inspectors they were "out of medication for their muscle spasms and pancreatitis sometime last month" and explained "they have chronic pain and not having the medication for their muscle spasms made their pain worse."

Records showed the resident missed three doses of Cyclobenzaprine for muscle spasms on May 19 and 20. They also missed six doses of Creon pancreatic enzymes between May 26 and 28. Administration notes repeatedly documented "medication needed refill" and "not available."

A registered nurse confirmed the resident "ran out of the medications and the medications had to be reordered from the pharmacy" but was "unable to provide evidence the medications had been reordered prior to the medication running out."

The facility's policy required medications to be reordered "not less than three days prior to the last dosage being administered." The Director of Nursing confirmed "there was not documentation the medication was reordered in the three day time frame required by policy."

Hospice coordination failures left critical medications undelivered for days. Resident 455, admitted to Gentiva hospice in May 2024 for end-stage heart failure, had a physician order for potassium chloride scanned into their medical record on June 4. The medication was never administered.

The licensed practical nurse assigned to the resident explained staff learned about hospice plans of care "by reviewing the resident's hospice binder and/or by speaking directly with hospice staff." When the nurse located the hospice binder, it "lacked a POC, orders, and communication between hospice and facility staff."

A bubble pack containing the ordered potassium chloride was found in the medication cart with no missing doses — evidence the medication had been delivered but never given to the resident.

The Director of Nursing confirmed the facility "lacked documented evidence the order for Potassium Chloride ER was communicated to the facility's physician, the facility's physician agreed with the order, and the order was entered into the EMR so it would reflect on the Medication Administration Record as needing to be administered."

During the inspection, the Director of Nursing had to call the facility physician to get a telephone order for the medication that had been sitting in the cart for over a week.

Safety failures put residents at risk of serious injury. Resident 98, admitted with urinary retention requiring a catheter, pulled out his catheter three times, causing bleeding and requiring emergency room visits each time.

Progress notes documented "gross hematuria due to traumatization to the resident's penis" after the May 23 incident. On May 27, "the resident's catheter came out with the balloon still intact. Bleeding was noted and the resident complained of pain to the resident's penis."

The resident's representative told inspectors the resident "had pulled the catheter out twice since admission to the facility and had to return to the hospital to have a new catheter inserted each time."

On June 12, the resident pulled out his catheter for the third time, "urinating bright red urine."

The licensed practical nurse confirmed the resident "used to have a leg strap in place to attach the catheter tubing to the resident's leg with the goal of preventing the resident from pulling the catheter out" but "did not have a leg strap or a StatLock in place when the catheter was pulled out."

The facility's catheter care policy required catheters to be "secured with a leg strap to reduce friction and movement at the insertion site."

A certified nursing assistant's annual performance evaluation was completed nearly two months late, violating the facility's policy requiring annual reviews "from the date of employment."

The Human Resources Manager confirmed Employee 8, hired May 18, 2022, should have received an evaluation by May 18, 2023, but wasn't evaluated until July 11, 2023.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Alta Skilled Nursing and Rehabilitation Center from 2024-06-13 including all violations, facility responses, and corrective action plans.

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