Health inspection·November 9, 2021

F684 Quality of Care, Section 483.25 Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. The following citation was written as a result of an unannounced visit to the facility on 4/22/21 to investigate Complaint #CA00734493, Complaint # CA00734430 and Facility Reported Incident (FRI) CA00731737. The Department determined the facility failed to ensure adequate supervision and direct assistance with a meal for one of three sampled residents (Resident 1) and failed to ensure her meal was provided in a texture Resident 1 could safely swallow. These failures led to difficulty with breathing and a rapid decline in her condition. This chain of events, coupled with a delay in Resident 1 receiving a higher level of care, ultimately contributed to Resident 1's death. On 4/22/21 an unannounced visit was conducted at the facility to investigate Complaint/Facility Reported Incident regarding Resident 1 who choked on 4/3/21 during the lunch meal. A review of Resident 1's "Admission Record," indicated, Resident 1 was originally admitted to the facility in late 2010 with diagnoses which included, dysphasia (difficulty swallowing foods or liquids), cognitive communication deficit (difficulty with thinking and speaking), dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), other problems related to: life management and care provider dependency. Review of the Minimum Data Set (MDS- an assessment tool), dated 3/3/21, indicated, Resident 1 scored two out of 15 in a Brief Interview for Mental Status (BIMS) which indicated severe cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The functional status section of the MDS indicated Resident 1 required supervision (oversight, encouragement, or cueing) and one-person physical assist for eating. During an interview, on 5/3/21, at 9:52 a.m., Certified Nursing Assistant (CNA) 1 explained, she had worked with Resident 1 for the last four months but did not recall Resident 1 having dentures in her mouth. CNA 1 stated, on the day of 4/3/21 she did not assist Resident 1 to place dentures in her mouth and explained if Resident 1 had dentures she would have assisted her to place them. During an interview, on 5/3/21, at 11:06 a.m., Licensed Nurse (LN) 1 stated, Resident 1 had top dentures only, no bottom dentures. Review of Resident 1's "Inventory of Personal Items," dated 11/13/17, indicated, "Dentures: 1. Upper 2. Lower..." had been marked as present on admission to the facility. Review of Resident 1's care plan, revised 4/25/17, indicated, "Focus...[Resident 1] is edentulous [lacking teeth] and receives a mechanically altered diet [food is chopped/blended so that it can be easily swallowed]...Interventions...Assure dentures are in place before meals-prompt and assist resident as needed..." Review of a physician's Orders Summary Report, dated 4/22/21 at 2:17 p.m., indicated Resident 1's diet was upgraded from a "dysphasia advanced texture" diet (soft foods that require chewing ability) to a regular diet (no alterations to the food consistency) on 4/1/21. During an interview, on 5/3/21, at 11:36 a.m., the Director of Rehabilitation (DOR) stated, after a diet upgrade a resident would be seen by Speech Therapy (ST) for a week to two weeks to ensure a resident was safe on the new diet. The DOR confirmed, Resident 1 had been expected to be followed by ST for one to two weeks post diet upgrade. The DOR explained, Resident 1 had been followed by ST five times a week, on a Monday through Friday schedule. The DOR stated, Resident 1's diet had been changed on 4/1/21 (Thursday). The DOR confirmed, Resident 1 had not been seen by ST on 4/2/21 or 4/3/21, following the diet change. The DOR explained, ST had worked on 4/2/21 (Friday) for an hour and a half but did not see Resident 1. The DOR stated, she was not sure why Resident 1 had not been seen on 4/2/21 (Friday). During an interview, on 4/22/21, at 9:03 a.m., Licensed Nurse (LN) 1 stated, she had been assigned to Resident 1 on the day shift on 4/1/21 (date of the diet change) and 4/3/21. LN 1 explained, Resident 1's diet had just recently been upgraded on 4/1/21, but LN 1 did not receive any specific recommendations to ensure a safe transition for a diet upgrade for Resident 1. During an interview, on 5/3/21, at 9:52 a.m., Certified Nursing Assistant (CNA) 1 stated, she had been assigned to Resident 1 on the 4/3/21 day shift. CNA 1 stated, she was unaware of Resident 1's recent diet change and did not receive any education regarding Resident 1's new diet or any specific instructions. During an interview, on 4/22/21, at 11 a.m., the DOR stated, ST will give a nursing communication form to nursing staff if there are any specific recommendations related to a diet upgrade. During an interview, on 4/22/21, at 12:06 p.m., Speech Language Pathologist (SLP) 1 stated, Resident 1 required intermittent cueing and a visual reminder to drink liquids between bites to ensure Resident 1 emptied her mouth of food. When asked if Resident 1 had choked in the past, SLP 1 stated, she had not been aware of any history for Resident 1 related to issues with eating. During an interview, on 4/27/21, at 5:08 p.m., Speech Pathologist Clinical Fellow (SPCF) 1 stated, Resident 1 required reminders while eating to complete a liquid wash (alternating solid foods with liquids). SPCF 1 explained, other recommendations for meals for Resident 1 included upright for all meals, small bites, and her food cut up. When asked if Resident 1 had choked in the past, SPCF 1 stated, she had not been aware of any history related to Resident 1 regarding issues with eating. Review of Resident 1's "Progress Note," dated 7/6/20, indicated Resident 1 had a history of choking on food: "Res [resident] was noted to have been coughing while she was eating lunch, staff went to see what was going on then saw resident choking on something. Give her a tap on the back still res noted to still choking...did heimlich manaveur [sp]...resident cough out a piece of her dinner roll..." Review of Resident 1's care plan, revised 4/25/17, indicated, "Focus... [Resident 1] is edentulous [lacking teeth] and receives a mechanically altered diet...Interventions...RESOLVED: Resident has an episode of choking on bread, speech therapy is going to eval [evaluate] and treat. Date Initiated 07/07/2020...Resolved Date: 04/05/2021..." During an interview, on 4/22/21, at 9:03 a.m., Licensed Nurse (LN) 1 stated, she was not sure why CNA 1 decided not to get Resident 1 up on 4/3/21 for her lunch meal. LN 1 stated, if staff went into Resident 1's room to get her up, Resident 1 would usually agree to get up in the chair. LN 1 stated, being up in the chair for a meal is always the best practice, especially with a diet change. During an interview, on 4/22/21, at 10:37 a.m., the Director of Staff Development (DSD) stated, the expectation would be for every resident to be up in their chair for every meal, if able. During an interview, on 4/22/21, at 12:06 p.m., SLP 1 stated, there had been a sign on Resident 1's bulletin board which had stated "Patient to be up in wheelchair for all meals." During an interview, on 4/29/21, at 3:34 p.m., the DSD explained, if a resident was at high risk for choking, the resident should be up out of bed in their wheelchair in a location where they can be visualized by staff. During an interview, on 5/3/21, at 9:52 a.m., CNA 1 stated, she had been assigned to Resident 1 on 4/3/21. CNA 1 stated, Resident 1 never really refused care. When asked if an attempt had been made to get Resident 1 up for the lunch meal on 4/3/21, CNA 1 stated, an attempt had not been made because "She just looked like she didn't want to get up." CNA 1 further explained, Resident 1 did not seem like she wanted to get up, "so I didn't even try." Review of Resident 1's nutrition care plan, revised 1/29/20, indicated, "Interventions...HIGHER RISK FOR CHOKING Date Initiated: 06/14/2016..." Review of an online document from Cedars Sinai indicated: "Aspiration from Dysphagia," (undated), in the section "How is aspiration from dysphagia treated?" indicated, "...The symptoms of dysphagia also need to be managed. This may include doing things such as: Not eating in bed..." In the section "What can I do to prevent aspiration from dysphagia?," indicated, "...Getting dental treatment (such as dentures) when needed...Sitting with good posture when eating and drinking..." (https://www.cedars-sinai.org/health-library/diseases-and-conditions/a/aspiration-from-dysphagia.html) During an interview, on 4/22/21, at 9:03 a.m., LN 1 confirmed, she had been the nurse assigned to Resident 1 on 4/3/21 when the choking event occurred. LN 1 stated, she heard a noise, entered Resident 1's room, and found Resident 1 had pocketed some food (holding food in the mouth without swallowing it). LN 1 stated, a phone call had been placed to the physician and the physician had requested for LN 1 to call the family to see if the family wanted to send Resident 1 to the hospital. During an interview, on 4/22/21, at 10:16 a.m., LN 1 stated, she had been at the facility on 4/3/21 up until the time Resident 1 had been sent to the emergency department (ED). LN 1 stated, from the time the choking incident occurred, to the time Resident 1 went to the ED, a registered nurse (RN) did not come to assess Resident 1. During an interview, on 4/22/21, at 10:37 a.m., the DSD stated, the facility is required to have a RN on duty 24 hours a day. During an interview, on 4/28/21, at 1:16 p.m., Resident Representative (RR) 1 stated, a licensed nurse had called on 4/3/21 and stated Resident 1 had choked on some chicken and asked, "Do you want her [Resident 1] to go to the hospital?" RR 1 explained, she did not know what to do and asked the licensed nurse what the doctor recommended. RR 1 explained, the licensed nurse responded, "He said to call you." RR 1 stated, the licensed nurse told her Resident 1's oxygen saturations [measure of oxygen level in the blood] went back up to 89 percent but did not state how much oxygen Resident 1 required at the time. During an interview, on 4/29/21, at 3:34 p.m., the DSD stated, a new need for oxygen would be considered a significant change in condition. During an interview, on 6/1/21, at 4:32 p.m., LN 2 stated, if a resident had a significant change in condition, and if the Director of Nursing or another registered nurse (RN) in administration was not in the building, the RN working on the floor would assess the resident. During a concurrent interview and review of the staff schedule, on 4/29/21, at 12:29 p.m., the Staffing Coordinator (SC) stated, on 4/3/21 there was no RN scheduled or on duty for the day shift (6 am to 2:30 p.m.). The SC stated, a RN is required to be in the building 24 hours a day. Review of Resident 1's meal ticket, dated 4/3/21, indicated, "...REGULAR...SATURDAY...LUNCH 4/3/21 FRIED CHICKEN...BUTTERED WHOLE KERNEL CORN...CORNBREAD...DUTCH APPLE PIE...POULTRY GRAVY...CRANBERRY JUICE - 8 oz [ounces]..." Review of Resident 1's "Progress Note," dated 4/3/21, indicated, "...At approximately 1320 [1:20 p.m.] this LVN [Licensed Vocational Nurse] heard this resident coughing. Upon entering the room this LVN assessed situation and found resident had pocketed her lunch and seemed to be choking. This LVN assisted resident to spit out remaining chicken. Resident still seemed to be having a hard time, assisted resident to lean forward and encourage her to cough. Upon doing so, another piece of chicken was dislodged...MD [medical doctor] notified of occurrence and new orders obtained for suction and PRN [as needed] O2 [oxygen]...Suction administered. O2 raised from 74% to between 88-91% on 4L [liters]-6L via mask..." Review of Resident 1's "Progress Note," dated 4/3/21, indicated, "...Writer received resident up in chair at nurses station with O2 via NC [nasal cannula] on 8L with saturations at 80%. Oxygen tank was changed and resident dropped to 53%. Resident was placed on non re-breather [a type of facemask used to deliver oxygen to a person] at 15 L and residents O2 went up to 67%...[Resident 1] was transferred to ER [Emergency Room] at 4:36 p.m. ..." Review of Resident 1's "SBAR [Situation Background Assessment Recommendations] Communication Form," dated 4/3/21, in the section "SITUATION," indicated, "...change in condition: Hypoxia [absence of enough oxygen in the tissues to sustain bodily functions] This started on: 04/03/2021 Since this started it has gotten: Worse... Things that make the condition or symptom worse are: Inability to clear airway...Things that make the condition or symptom better are: O2 and suctioning..." In the section "BACKGROUND," indicated, "...Vital Signs...RR [respiratory rate - normal respiratory rate for adults is 12 to 20 breaths per minute]: 26...Pulse Oximetry [measures the oxygen levels in your blood - normal range 92% to 100%, a level of at least 90% will prevent tissue injury] (if indicated): 71% on...O2 (Oxygen via Mask)...Respiratory Evaluation...Abnormal lung sounds...labored or rapid breathing...shortness of breath...cough...productive..." Review of Resident 1's undated "Order Summary Report," indicated, "O2 [oxygen] to keep sats [oxygen saturations measured with a pulse oximeter] [greater than] 90 as needed for SOB [shortness of breath]... Order Date 04/03/2021...Start Date 04/03/2021..." Review of Resident 1's "Weights and Vitals Summary," in the section "O2 sats Summary," indicated, "04/03/2021 07:18 [a.m.] 97% (Room Air)..." In the section "Respiratory Summary," indicated, "04/03/2021 16:45 [4:45 p.m.] 26 Breaths/min [minute]...04/03/2021 07:18 [a.m.] 16 Breaths/min..." No other O2 saturations or respiratory rates recorded for the date of 4/3/21 on Resident 1's "Weight and Vitals Summary." Review of an emergency department medical record for Resident 1, titled "ED [emergency department] Physician Notes," dated 4/3/21, indicated, "...Dyspnea [difficult or labored breathing]..Associated Diagnosis: Aspiration of foreign body [when an object is accidentally inhaled into a person's airways]; Pneumonia [an infection that inflames the air sacs in one or both lungs], Acute respiratory distress [when fluid collects in the lungs' air sacs, depriving organs of oxygen]...." In the section "History of Present Illness," indicated, "[Resident 1] presents to the emergency department from [facility name] with hypoxia and difficulty breathing...According to EMS [Emergency Medical Services], [facility name] told them that the patient [Resident 1] aspirated chicken around 2 PM. They apparently tried to suction her airway by instilling saline, but she continued to be with increased work of breathing and hypoxic [the body or a region of the body is deprived of adequate oxygen supply at the tissue level] so they [the facility] called 911 three hours later..." In the section "Reexamination/Reevaluation," indicated, "1700 [5 p.m.]: on arrival patient [Resident 1] is in significant distress with RR 30's, O2 75% on OxyMask [oxygen delivery mask]..." Review of a hospital medical record for Resident 1, titled "Discharge Summary," dated 4/8/21, in the section "FINAL DIAGNOSIS," indicated, "Acute aspiration pneumonia acute hypoxic respiratory failure sepsis [the body's overwhelming and life-threatening response to infection that can lead to tissue damage, organ failure, and death] secondary to aspiration pneumonia dementia with agitation hypotension [low blood pressure] secondary to sepsis..." In the section "HOSPITAL COURSE," indicated, "...patient continued to be struggling, and desaturating [oxygen levels dropping]. She would frequently remove her oxygen and refused deep suctioning and other interventions...transition to comfort measures only after discuss