Health inspection·June 13, 2022

Avocado AA citation . Mangum Intent served 4/5/22 Citation served 6/13/22 §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. § 72301. Required Services. (f) The facility shall ensure that all orders, written by a person lawfully authorized to prescribe, shall be carried out unless contraindicated. § 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: ... (C) Reviewing, evaluating, and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. (c) Licensed nursing personnel shall ensure that patients are served the diets as ordered by the attending licensed healthcare practitioner acting within the scope of his or her professional licensure. § 72315. Nursing Service - Patient Care. (g) Each patient requiring help in eating shall be provided with assistance when served and shall be provided with training or adaptive equipment in accordance with identified needs, based upon patient assessment, to encourage independence in eating. § 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. (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the patient care policy committee. A long-term health care facility shall provide supervision and assistance to prevent accidents or harm to those residents who have been previously identified as requiring supervision for safety precautions. The facility failed to: 1. Provide Resident 1 with one to one (1:1) assistance with feeding (when a staff member assists the resident throughout the meal, with verbal queuing), as indicated by the Speech Therapist Plan of Care and Physician's Order. 2. Update and implement the patient care plan to reflect the Speech Therapist Plan of Care and Physician's Order, which indicated Resident 1 was to receive 1:1 assistance and feeding by an RNA (restorative nursing assistant-an advanced certified nursing assistant {CNA} with additional training and certification such as feeding residents identified as high risk for swallowing difficulties). 3. Implement its policy titled, "Guidelines for Supervision and Assistance with Feeding," which indicates that Assistance 1:1 requires direct assistance of one staff member to one resident. 4. Implement its policy and procedure titled, "Restorative Feeding Program," which indicates staffing shall include one RNA/CNA to six residents. This failure resulted in Resident 1 expiring after she was left unsupervised to eat her lunch, and she aspirated (when food enters the lungs) food, causing asphyxiation (deprived of oxygen). On 11/22/21, an unannounced visit was conducted at the facility to investigate the quality of care provided for a resident (1) who was sent out to the hospital for aspiration risk. Resident 1 was re-admitted to the facility on 9/28/21, with diagnoses which included dementia (progressive memory loss), and failure to thrive (weight loss, decreased appetite and poor nutrition), per the facility's Resident Face Sheet. According to the physician's History and Physical, dated 9/17/21, Resident 1 did not have the capacity to understand and make decisions. Per the Admission Registered Dietician (RD) Nutritional Observation notes, dated 9/17/21, the resident's hospital weight was 81 pounds, and the resident was consuming 0-25% of her meals. Multiple pressure ulcers (breakage of skin from prolonged pressure) were present, and interventions were implemented which included a Speech Therapist (ST- a specialist who assists residents with difficulty talking, swallowing and chewing) evaluation, high protein supplements, and vitamins. According to the ST Evaluation and Plan of Care, dated 10/5/21, Resident 1's plan of care included speech therapy treatments two times a week for dysphagia (difficulty swallowing) related to dementia. Resident 1's diet was downgraded to pureed solids (a smooth textured modified diet, to assist with easy swallowing) and thin liquids. The ST 1 recommended strict aspiration/swallowing precautions, with 1:1 assistance during all meals. The ST documented the resident's caregivers were educated on safe swallowing precautions. Per the ST Treatment Encounter note, dated 10/27/21, the resident was evaluated for a trial mechanical soft diet (foods that are soft and easy to chew/swallow). ST 2 documented Resident 1 took large rapid bites, was holding bolus (food mixed with saliva and held in mouth), with prolonged/slow mastication (chewing food). The ST 2 recommended strict aspiration/swallowing precautions, with 1:1 assistance with all meals..." According to the Physician's Order Report, dated 10/29/21 through 11/08/21, (discontinue date) " ...Diet: mechanical (extra nutrients added), soft textured, ground meat/thin liquids. 1:1 assistance. Strict aspiration and swallow precautions. Special Instructions: RNA FEEDING **Awaiting DC {discontinued- meaning the discontinue date for RNA assistance with feeding was pending verification from the physician and speech therapist after an evaluation could be conducted} verification (DC dated 11/08/21) ..." Per the ST Treatment Encounter note, dated 11/8/21, ST 1 documented Resident 1 was occasionally taking multiple bites prior to swallowing, however she did eventually clear her oral cavity (mouth). ST 1 recommended diet upgrade to regular solids with continued 1:1 feeding assistance and continued supervision throughout meals. According to the Physician's Order Report, dated 11/08/21 through 11/19/21, (discontinue date) " ...Diet: Fortified, Regular textured/thin liquids 1:1 assistance. Strict aspiration and swallow precautions. RNA FEEDING **Awaiting DC verification {meaning the discontinue date for RNA assistance with feeding was pending verification from the physician and speech therapist after an evaluation could be conducted} verification DC dated 11/19/21) ..." Per the ST Treatment Encounter note, dated 11/15/21, the ST 2 documented, " ...turkey sandwich with graham cracker and water via cup ...Pt (patient) with multiple bites prior to swallow and benefited from verbal/visual cues to slow down/finish one bite first ..." Continue with ST plan of care, provided instructions to nursing staff in safe swallow strategies specifically, one bite at a time, slow rate, alternate solid/liquids, upright position. According to Resident 1's care plan titled, Requires RNA feeding, dated 10/13/21, indicated, " ...communicate with RNA of resident needing assistant during feeding ...verbal ques such as Take a bite or Pick-up the spoon." However, there was no documented evidence of a 1:1 feeding listed as an intervention on the RNA care plan. Additional care plans were reviewed to include Speech Therapy, dated 10/5/21, and Nutritional Status, dated 9/17/21, both of which were not revised to include documentation of 1:1 feeding. According to the Resident Progress Notes, dated 11/19/21, at 1:24 P.M., Licensed Nurse 1 (LN 1) was notified by Certified Nursing Assistant 1 (CNA 1) that, "something was wrong" with Resident 1. LN 1 documented Resident 1 had a grayish tint, with a clenched jaw, and was struggling to catch her breath. 911 was called and LN 1 lifted Resident 1 up in her chair by her arms, in an attempt to clear Resident 1's airway. LN 1 documented Resident 1 coughed and then clenched her jaw again and showed signs of difficulty breathing. Resident 1's oxygen saturation (an external device which measures the amount of oxygen in the blood) was 35% (normal 98%). Resident 1 was then transported to the hospital at 1:15 P.M., and the family was notified. The next Resident Progress Note, dated 11/19/21, at 3:48 P.M., LN 2 documented the hospital called informing them Resident 1 had expired. The facility's Registered Dietician (RD) was not available for an interview on 11/29/21. On 11/29/21, at 12:46 P.M., an interview was conducted with LN 1. LN 1 stated on 11/19/21, she was approached by CNA 1, who said something was wrong with Resident 1. LN 1 stated she entered Resident 1's room with CNA 1. LN 1 stated Resident 1 was sitting in her wheelchair and appeared gray in color. LN 1 stated she attempted to open Resident 1's mouth, but Resident 1's jaw was clenched. LN 1 yelled for help and lifted Resident 1 up by both arms to re-position her in the wheelchair. LN 1 stated Resident 1's color improved, she coughed, and then she re-clenched her jaw. LN 1 stated two respiratory therapists (RTs) arrived about that same time. The RTs moved Resident 1 to her bed and placed a non-rebreather mask, (special medical device that helps provide oxygen in emergencies) on Resident 1, as she sat up in bed. LN 1 stated Resident 1 remained awake, but lethargic (sluggish) until the paramedics arrived about 5-10 minutes after she was placed in bed. LN 1 stated she did not perform the Heimlich maneuver, (a first-aid procedure for dislodging an obstruction or food from a person's windpipe, which is performed by applying a thrust to the upper abdomen) because Resident 1 was breathing, and her color had improved after she was re-positioned in the wheelchair. LN 1 stated Resident 1's color started to slightly change again to a gray tint, but she was still breathing on her own with the oxygen mask on, and they could not suction her because her jaw remained clenched. LN 1 continued, stating Resident 1's food tray, at the time contained soup, which looked like chicken stew with two spoons in the bowl, a chopped salad, corn bread and an apple crumble dessert. LN 1 stated Resident 1 had no previous problems while eating. LN 1 stated if a resident was on RNA 1:1 feeding, that meant an RNA should be doing the feeding. LN 1 stated RNAs had more training than CNAs, along with extra certifications. On 11/29/21, at 1:08 P.M., an interview and record review were conducted with the Dietary Services Supervisor (DSS). The DSS printed out Resident 1's meal ticket for lunch on 11/19/21, which was listed as "Fortified regular diet texture with thin liquids RNA 1:1 feeding assistance." The lunch calendar was reviewed for 11/19/21. The lunch meal consisted of White chili with chicken, salad, cornbread, and an apple brown betty dessert. On 1/29/22, at 1:28 P.M., an interview and record review were conducted with ST 1. ST 1 stated she initially evaluated Resident 1 and recommended puree diet with thin liquids, due to her dementia and history of forgetting to swallow her food. ST 1 stated she recommended 1:1 feeding because Resident 1 was an aspiration risk. ST 1 stated she discussed the plan of care with the resident's physician, who agreed with the 1:1 feeding for supervision and cueing. ST 1 reviewed Resident 1's ST Progress Reports and stated on 10/29/21, the resident's diet was upgraded after discussing the resident's progress with the physician, to a fortified mechanical soft diet with thin liquids. ST 1 stated Resident 1 was still considered an aspiration risk and 1:1 feeding was continued. ST 1 stated Resident 1 continued to improve with the twice a week evaluation and was developing better eating patterns with small bites and chewing her food. ST 1 continued to review Resident 1's ST Progress Reports and stated on 11/08/21, Resident 1's diet was upgraded again by the physician to a fortified regular textured diet with 1:1 assistance for all meals and strict aspiration and swallow precautions were to be followed. ST 1 stated Resident 1 was doing extremely well, her weight was up, and she was feeding herself, but she still required cueing and verbalization because she could not remember the task at hand. ST 1 continued to review Resident 1's ST Progress Reports and stated she recommended 1:1 feeding, but she did not request RNA feedings, because the RNA feeding order came directly from Resident 1's physician. ST 1 stated when the physician entered the RNA feeding order, a care plan should have been developed or revised to reflect the RNA 1:1 feeding with the specific diet ordered. ST 1 stated the LNs were responsible for care plan updates and revisions to reflect RNA feeding, due to weight loss or swallowing difficulty. ST 1 stated she probably would have kept Resident 1 on 1:1 feeding indefinitely, due to her declining memory loss. On 11/29/21, at 2 P.M., an interview was conducted with CNA 1. CNA 1 stated she usually worked the P.M. shift (3 P.M. to 11:30 P.M.) on Station 4 and had taken care of Resident 1, maybe twice before. CNA 1 could not recall if Resident 1 was a 1:1 RNA feed at that time. CNA 1 stated that 11/19/21 was her first time working on the day shift on Station 4. CNA 1 stated she was told in the morning huddle she was assigned to three residents in the room closest to the nurse's station, and all three residents in that room were on 1:1 room supervision due to their confusion. CNA 1 stated on 11/19/21, she noticed Resident 1's breakfast tray was still sitting near Resident 1 covered. CNA 1 said she went to the nurse's station and was told by an unknown CNA that there were no available RNAs that day to feed Resident 1. CNA 1 stated she took it upon herself to feed Resident 1, without asking anyone if it was alright. CNA 1 stated she did not inform the charge nurse that the RNA had never arrived to feed Resident 1. CNA 1 stated she was still sitting with Resident 1, who was finishing her breakfast, when another CNA, who she could not identify, passed by the resident's room and said Resident 1 was no longer a 1:1 feeding, and was now considered a "supervised feeding (per the facility's policy: Guidelines for Supervision and Assistance with Feeding, Supervision 1:1, one staff member to one resident to...minimize risk of aspiration)." CNA 1 continued, stating, "supervised feeding" meant the CNA must be around or nearby in case the resident needed assistance. CNA 1 could not name the CNA who told her this, and could not describe the person, saying she could not even recall if it was a male or female who told her Resident 1 was now a "supervised feeding." CNA 1 stated she did not verify this information with the unit charge nurse, and she did not check the facility's CNA Communication book which contained "Special Instructions" for care. CNA 1 continued, stating the next meal on 11/19/21, was lunch. CNA 1 remembered preparing Resident 1's lunch tray by uncovering her soup, salad, drinks and tearing up the resident's cornbread into little pieces. CNA 1 stated she left Resident 1 in her wheelchair next to her bed, to feed herself and went to the next bed to feed her roommate, Resident 5. CNA 1 stated she was feeding Resident 5, with her back to Resident 1, when she heard noises coming from behind her. CNA 1 stated she turned her head to look over her shoulder and noticed Resident 1 did not look right. CNA 1 stated she left the resident's room to get help. CNA 1 returned to Resident 1's room within seconds with LN 1. CNA 1 stated LN 1 lifted Resident 1 up in her wheelchair, which seemed to help for a few seconds, but then Resident 1 started to have trouble breathing. CNA 1 stated she remembered looking at Resident 1's food tray and could tell the resident ate some soup, but she could not recall if anything else had been consumed from Resident 1's lunch tray. On 11/29/21, at 2:10 P.M., an in