Health inspection·May 10, 2023

F684 42 CFR § 483.25 Quality of care 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. F- 689 42 CFR §483.25(d) Accidents. The Facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate Supervision and assistance devices to prevent accidents. 22 CCR §72523. Patient Care Policies and Procedures. (a)Written patient care policies and procedures shall be established and implemented to ensure that patient- related goals and facility objectives are achieved. 22 CCR § 72311. Nursing Service--General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. On 2/25/20 at 11:39 A.M., an unannounced onsite visit was conducted related to a report of an unusual occurrence (death). It was determined the facility failed to provide supervision during mealtime for Resident 1, who was identified as high risk for choking and diagnosed with dysphagia (difficulty swallowing). The facility failed to: 1. Provide quality of care based on a comprehensive assessment and care plan by serving Resident 1 their meal tray, proceeding to pass other remaining meal trays out, thereby leaving Resident 1 unsupervised while eating. 2. Identify as part of the care plan Resident 1's need for mechanical diet as ordered by the physician. 3. Ensure the environment remains free of accidents and hazards by leaving Resident 1 unsupervised with food and by inadequate staff monitoring of Resident 5 during mealtime. 4.Follow patient care policies and procedures requiring that Residents who cannot feed themselves will be fed with attention to safety and shall receive assistance with meals in a manner that meets the individual Resident's needs. As a result, Resident 1 was found at the dining room table with her head slumped over and skin bluish in color from a lack of oxygen. The Registered Nurse (RN 1) found the resident unresponsive, called 911, and the resident died at the facility from airway obstruction due to a food bolus (small, rounded mass of a substance). During the unannounced visit to investigate the death of Resident 1, it was also observed that a certified nursing assistant (CNA 2) remained standing and talking to another resident while feeding Resident 5. CNA 2 did not visually check Resident 5 to check if she was chewing the food. Findings: A review of the facility's Resident Information indicated, Resident 1, a 65-year-old female, was readmitted to the facility on 1/30/20, from an acute care hospital for long term care after she had an altered level of consciousness. Per the Resident Information, Resident 1 had diagnoses which included encephalopathy (brain disease, damage, or malfunction), and dyskinesia (involuntary movement). A review of Resident 1's Minimum Data Set assessment (MDS - an assessment tool) dated, 2/6/20, the resident had a BIMS (brief interview for mental status) score of 13 out of 15 (which meant cognitively intact). The Activities of Daily Living (ADL) indicated, "Eating- Total dependence with one-person physical assist..." The same MDS for functional abilities indicated, "Resident 1 required supervision...while eating." A review of Resident 1's physician order, dated 1/30/20 indicated, "Diet: Fortified NAS (no-added salt), mechanical (mech) soft diet, ground meat." A review of Resident 1's initial care plan, dated 1/31/20, indicated Resident 1's identified potential problem was aspiration/swallowing problem and risk for choking. Interventions indicated, "Assess...ability to do activities of daily living (ADL) such as ...eating..." The care plan did not reflect the physician's order of mechanical soft diet for Resident 1. A review of Resident 1's ADL care plan for Eating, dated 1/31/20, indicated, "Eating independent Full assist with fluids." One of the interventions documented was to "...anticipate resident's needs and provide appropriate level of assistance as needed..." A review of the facility's untitled document dated 2/5/20, indicated, "... [facility name], PROB (sic)/NEED indicated, "...tends to eat very fast which places...at risk for choking accidents and or aspiration...Interventions: gently remind resident to eat slowly and to chew her food adequately before swallowing, encourage small bites as possible...provide assistance as needed (staff needs to assist resident with fluids fully due to hand tremors)" A review of the Dietary Progress Notes, dated 2/7/20 by the Dietary Services Supervisor (DSS), indicated Resident 1 was noted to eat rapidly during mealtimes. A review of the Nutritional Status dated 2/7/20, by the DSS, indicated Resident 1 was at risk for choking and aspiration. Resident 1's goal was there will be no signs and symptoms of choking and aspiration. A review of Resident 1's OT (Occupational Therapist) Progress notes dated, 2/17/20, OT 1 documented, Resident 1 was self-fed, and the prior level and current level of functioning from 2/1/20 to 2/17/20 was supervision (needs verbal cueing but no physical assist). A review of Resident 1's nursing progress notes dated 2/20/20 indicated, "At 11:50 in the morning, nursing staff started passing out trays to the residents in the dining room. This resident (Resident 1) sits on the first table therefore they get served their meal trays first. While nursing staff continued to pass the remaining meal trays out, resident seatmate noted that the resident was slumped over and cyanotic (bluish in color from a lack of oxygen)...started yelling for help...this writer (RN 1) suspecting she (Resident 1) might have choked, ...called CNA (CNA 3) to provide abdominal thrust but nothing came out...despite multiple attempts...summoned others from the upper building for help...Upon other staff's arrival, resident was moved onto the floor from the chair and CPR was initiated. At 12:15 p.m., paramedics arrived ...took over giving them the hand-off report. At 12:20 P.M., ...the 911 determined that the resident had died, they reported ...to conduct their investigation...At 1:20 P.M., Coroner officer investigates...at the facility...took the resident's body to the coroner's office for further investigation..." A review of the medical examiner's report dated 2/21/20 indicated, "Cause of Death: Asphyxiation by airway obstruction due to choked on food bolus ...Manner: Accident ..." On 2/25/20 at 12:45 P.M., an interview with RN 1 was conducted. RN 1 stated Resident 1 ate lunch in the dining room with the first group. RN 1 stated on 2/20/20 during lunchtime, she (RN 1) and two other certified nursing assistants (CNAs 3 and 4) were passing residents' meal trays. Resident 1 was served with her lunch tray. RN 1 stated a CNA (CNA 3) served the meal tray to Resident 1. RN 1 stated Resident 1 was independent however, Resident 1 required supervision and cueing to eat slowly due to the "resident's medical condition, dyskinesia" (involuntary movement). RN 1 stated during that day, she was assisting to feed another resident when a CNA (4) called her to check Resident 1. RN 1 stated Resident 1 was already cyanotic, and her head was slumped over the table. RN 1 stated she opened Resident 1's mouth and did not see anything. RN 1 stated she asked CNA 3 to perform abdominal thrust, but nothing came out. RN 1 stated she called for help. Another Licensed Vocational Nurse (LVN 2) came and called 911. RN 1 stated cardiopulmonary resuscitation (CPR - an emergency procedure that combined chest compression and artificial ventilation) was initiated, until the paramedics came. On 2/25/20 at 2:07 P.M., an interview with CNA 1 was conducted. CNA 1 stated she took care of Resident 1 on 2/19/20. CNA 1 stated Resident 1 ate fast and required verbal cueing to slow down. In addition, Resident 1 tended to drink fast which caused her to cough. On 2/26/20 at 9:23 A.M., a telephone interview with CNA 4 was conducted. CNA 4 stated on 2/20/20, she was assigned to provide care for Resident 1. CNA 4 stated on 2/20/20, she was passing lunch meal trays when Resident 2 called her to check Resident 1. CNA 4 stated she went to check the resident. Resident 1's lips were pale and black/blue, she (CNA 4) then called RN 1. CNA 4 stated RN 1 performed abdominal thrusts and CNA 4 relieved RN 1. RN 1 then asked for help and initiated CPR until paramedics arrived. CNA 4 stated she was unsure if Resident 1 ate or drank during lunch because no one supervised the resident. They (RN 1 and the two CNAs 3, 4) were still passing the meal trays. On 2/27/20 at 1:33 P.M., a telephone interview with CNA 3 was conducted. CNA 3 stated she was serving lunch trays to other residents when CNA 4 called her. CNA 3 stated she was not sure if Resident 1 had eaten lunch. CNA 3 stated abdominal thrusts were started but nothing came out from Resident 1's mouth. Resident 1 was placed flat on the floor and CPR was initiated per RN 1's direction until the paramedics came. On 5/24/22 at 9:38 A.M., a telephone interview with the Dietary Services Supervisor (DSS) was conducted. The DSS stated she could still remember Resident 1. The DSS stated Resident 1, "She eats fast, scoops her spoon and puts in her mouth, we have to inform her to slow down." The DSS stated Resident 1 required supervision with eating. The DSS stated Resident 1's diet was ground meat for easy chewing. The DSS stated she wrote Resident 1's nutritional care plan that indicated "Tendency to choke so CNA has to watch her since she could eat independently..." The DSS stated CNAs and LNs (Licensed Nurses) were responsible to remind Resident 1 because she was not there all the time. The DSS stated Resident 1 was upset when people reminded her to slow down. On 5/24/22 at 9:58 A.M., a telephone interview with the Director of Nursing (DON) was conducted. The DON stated Resident 1 was independent with all ADLs and wanted to be independent. The DON stated Resident 1 ate rapidly, "That time, they (RN and CNAs) were passing the tray, for all we knew, she stuffs her food in her mouth..." The DON stated Resident 1 needed reminders to eat slowly because of her impulsiveness. The DON stated the staff should have watched her and reminded her to eat slowly. The DON stated it happened as soon as the staff turned their back to serve another resident. The DON stated it happened very quickly and was an unfortunate situation. A review of the facility's Resident Information indicated Resident 5 was an 80-year-old female admitted to the facility on 5/24/17 from Rehabilitation (Rehab) hospital, with diagnoses which included dysphagia (difficulty swallowing). On 2/25/20 at 11:59 AM, a lunch observation was conducted in the dining room of Building 1. There were five tables in the dining room, 14 residents were seated at the dining table. Three nursing staff were serving meal trays to the residents. On 2/25/20 at 12:06 P.M., Resident 5 was sitting in her wheelchair at table four. An empty chair was available at an adjacent table. Certified Nursing Assistant (CNA) 2 was standing while assisting and feeding Resident 5. In addition, CNA 2 was talking to another resident at table four, while assisting Resident 5 with meals. CNA 2 left the dining area at 12:31 P.M. after assisting Resident 5. On 2/25/20 at 12:45 P.M., an interview with the Registered Nurse (RN) 1 was conducted. RN 1 stated CNA 2 should have sat down while feeding Resident 5 to maintain eye level. On 2/25/20 at 1:09 P.M., an interview with CNA 2 was conducted. CNA 2 stated it was their policy, " ...to always supervise and visually check on the residents, to ensure the residents could chew and swallow their food." CNA 2 stated she was standing while feeding Resident 5 and should have sat down to see if Resident 5 ate and chewed the food carefully. On 2/25/20 at 1:36 P.M., an interview with the Director of Nursing (DON) was conducted. The DON stated his expectations for the staff was to sit down when assisting and feeding the residents to maintain eye level with the residents. The DON further stated sitting down while feeding the resident would give the CNA the chance to visually check residents with swallowing problems. A review of the facility's policy titled, Assistance with Meals, revised 9/2013, indicated, " ... Residents who cannot feed themselves will be fed with attention to safety ...", and "Residents shall receive assistance with meals in a manner that meets the individual needs of each resident ..." The facility failed to: 1. Provide quality of care based on a comprehensive assessment and care plan by serving Resident 1 their meal tray, proceeding to pass other remaining meal trays out, thereby leaving Resident 1 unsupervised while eating. 2. Identify as part of the care plan Resident 1's need for mechanical diet as ordered by the physician. 3. Ensure the environment remains free of accidents and hazards by leaving Resident 1 unsupervised with food and by inadequate staff monitoring of Resident 5 during mealtime. 4. Follow patient care policies and procedures requiring that Residents who cannot feed themselves will be fed with attention to safety and shall receive assistance with meals in a manner that meets the individual Resident's needs. These violations jointly, separately, or in any combination, presented either imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result.