Health inspection·July 11, 2024

The following reflects the findings of the California Department of Public Health during a recertification survey, Survey Event ID: CLFR11. Representing the Department, HFEN (Health Facilities Evaluator Nurse) # 47046 State Citation (A) was written. Code of Federal Regulations, Title 42, Section 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 resident's choices. Code of Federal Regulations, Title 42, Section 483.25(d) Accidents. The facility must ensure that - (1) The resident environment remains as free of accident hazards as is possible. (2) Each resident receives adequate supervision and assistance devices to prevent accidents. California Code of Regulations, Title 22, Section 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. California Code of Regulations, Title 22, Section 72523 (a) 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. On 6/3/24 at 8 a.m., an unannounced visit was conducted at the facility for an annual recertification survey. The Department determined the facility failed to ensure a safe environment when Resident 15 had access to, and consumed, restricted food on 3/24/24 and choked. This failure put Resident 15 at risk for death due to choking and resulted in her hospitalization on 3/24/24, which resulted in the insertion of a feeding tube into the stomach for nutritional support. After the choking incident and hospitalization Resident 15 was no longer able to consume food and liquids by mouth which had the potential to effect Resident 15's quality of life. A review of Resident 15's Admission Record indicated Resident 15 was admitted to the facility with multiple diagnoses which included, hemiplegia (weakness on one side of the body), and food in larynx (throat) causing asphyxiation (process of being deprived of oxygen, which can result in unconsciousness or death; suffocation), dysphagia (difficulty swallowing), cognitive communication deficit (a person has difficulty communicating because of injury to the brain that controls the ability to think), and major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). A review of Resident 15's care plan initiated on 9/16/23, indicated, "... [Resident 15] is at risk for aspiration [when something that is swallowed gets in the lungs]...Dysphagia [Difficulty in swallowing] ...interventions ...Resident will be given snacks by staff after ensuring it follows her diet and diet texture [meals or drinks that have been prepared in a special way to create a certain texture or consistency] ...RESIDENT WILL BE ON ASPIRATION PRECAUTION ...Residents tray and snacks will be checked before giving to patient ..." A review of Resident 15's Minimum Data Set (MDS- an assessment tool used to guide the care of a resident) section C, dated 5/3/24, indicated Resident 15 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition, the ability to think and understand) score of 7 out of 15 (The BIMS assessment uses a points system that ranges from 0 to 15 points: 0 to 7 points suggests severe cognitive impairment, 8 to 12 points suggests moderate cognitive impairment, 13 to 15 points suggests that cognition is intact). A review of Resident 15's nutrition assessment titled, "Nutritional Assessment V 1," dated 3/4/24, the sections "Diet Texture" and "Thickened Liquids" indicated, Resident 15 was on a Dysphagia Puree [food with the consistency of mashed potatoes to make swallowing easier] and Nectar like diet [drinks with the consistency of thick syrup]. A review of Resident 15's physician order, dated 3/7/24, and titled "Order Summary Report", indicated " ...Fortified [Foods that have added calories and protein] NAS [No Added Salt] diet Puree texture, thick liquids-Nectar consistency ...** STRICT PRECAUTIONS** related to DYSPHAGIA ..." A review of Resident 15's nursing progress note, dated 3/8/24, at 5:50 p.m., indicated, "Resident was seen by staff coming to nurses station and taking left over snacks left during AM [Morning shift] not proper for patient diet. Resident on puree diet and took a sandwich and Graham crackers, nurse told resident she could not have those snacks and offered pudding or applesauce in substitute, but resident refused...." A review of Resident 15's "Speech Therapy SLP [Speech Language Pathologist (specialist)] Evaluation & Plan of Treatment" "Certification Period: 3/18/2024-4/14/2024" indicated, "...Patient ...found to have a swallowing disorder ...Definite risk for: Aspiration, Delayed or slow swallow reflex ..." A review of Resident 15's nursing progress note, dated 3/24/24, indicated, " ...around 1545 [3:15 p.m.] roommates family member came to get nurse stated there was something wrong with the resident. Nurse went into residents room and found resident in her chair staring at the sky blinking but not talking. Nurse noticed resident had food stuck in her throat. Nurse tried to the [sic] dislodge food but could not. Nurse yelled for help. CNA [Certified Nursing Assistant] yelled that resident was choking on Graham crackers. At approximately 1550 [3:50 p.m.] UM [Unit Manager] went in to assist with Heimlich maneuver [sudden upward pressure on the upper abdomen of a choking victim to force a foreign object from the airway] along with other nurses. Airway was still partially obstructed [blocked] when UM performed Heimlich. Sating [Measurement of oxygen in blood] at 75 to 80% [95%-100% is the normal range] and suction [A process of inserting a small tube into the airway to remove blockages] was given. Some cracker pieces were noted when suctioned. Heimlich, oxygen and suction continued until firefighters arrived at approximately 1555 [3:55 p.m.]. Resident was sent out to [acute care hospital name]. approx.[approximately] 1600 [4 p.m.] ..." A review of Resident 15's hospital discharge summary, dated 3/29/24, indicated, "Patient [Resident 15] was admitted 3/24/24 with aspiration PNA [Pneumonia- infection of the lungs] after choking on food at [Facility] ...Patient ...presents to the ED [Emergency Department] after a choking episode and found to be saturating in the 50's on admission resulting in intubation [a tube inserted into the airway used to deliver oxygen to the body] in the ED ...Patient was admitted for management and evaluation of acute hypoxic respiratory failure [when the body lacks enough oxygen in the blood] secondary to choking episode resulting in aspiration pneumonia ... Patient intubated on arrival and extubated [a process where the inserted tube is removed from the airway] on 03/26...Patient failed ST [speech therapy] evaluation [to determine if patient is able to consume foods safely]...PEG tube placement...Tube Feedings (nutrition delivered to the body through a tube)- Continuous ...Route of admin [Administration]: Small Bowel Feeding Tube [a tube that is surgically placed in the gut] ..." Review of Resident 15's "Admission Summary" note, dated 4/3/24, indicated, "...Admitted...from [name of hospital] ...Admitting dx [diagnosis]: acute hypoxic respiratory failure [occurs when the air sacs of the lungs cannot release enough oxygen into the blood], aspiration of food, chocking [sp] episode. With G-tube [gastrostomy tube (also called a G-tube) is a tube inserted through the belly that brings nutrition directly to the stomach] for continuous feeding..." A Review of Resident 15's physician order, dated 4/3/24, indicated, " ...NPO (Nothing by mouth) diet NPO texture, NPO on all fluids..." Review of Resident 15's "Speech Therapy SLP Evaluation & Plan of Treatment," dated 4/4/24 - 5/1/24, indicated, "...Patient seen...for a cognitive assessment and dysphagia screener...Patient with PEG [Percutaneous endoscopic gastrostomy; a medical procedure in which a tube is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding] tube placement...Pt [patient] was noted with an immediate cough and wet vocal quality post swallow. Delayed swallow initiation observed...SLP recommends the patient continue NPO...When asked if patient would like to continue with ST services she states "I guess but I'm going to die soon" ...Due to the documented physical impairments and associate functional impairments, the patient is at risk for: falls, aspiration, depression and pneumonia [an infection in the lungs caused by bacteria]..." A review of Resident 15's nutrition assessment titled, "Nutritional Assessment V 1," dated 4/10/24, in the section "Diet order" indicated, Resident 15 was receiving nutrition through a feeding tube. A Review of Resident 15's physician order, dated 6/4/24, indicated, " ...Enteral Feed [nutrition given through a tube] Order five times a day ..." During an interview on 6/6/24 at 8:50 a.m., Licensed Nurse (LN) 4 stated, all snacks used to be kept at the nursing station. LN 4 stated they (facility/staff) were no longer keeping any snacks at the nursing station after Resident 15 choked on crackers. LN 4 explained metal gates were installed at the entrances to the nursing stations in the facility for the safety of the residents. During a concurrent interview and record review on 6/6/24, at 9:22 a.m., with LN 13, Resident 15's physician order dated 3/7/24 was reviewed. The physician order indicated Resident 15 was on a fortified pureed nectar thickened diet, confirmed by LN 13. LN 13 stated Resident 15's physician order dated 4/3/24, indicated Resident 15 was now NPO and required a feeding tube. LN 13 further stated Resident 15 could have died from choking and the incident was avoidable. During an interview on 6/6/24 at 10:35 a.m. with the Director of Staff Development (DSD), the DSD confirmed Resident 15 choked on crackers. The DSD stated this was an unfortunate incident and could have been avoided. The DSD further stated after the incident metal gates were installed on both nursing stations and they should be locked all the times. During a concurrent interview and record review on 6/6/24, at 1:45 p.m. with the Director of Nursing (DON), Resident 15's 3/24/24 progress notes were reviewed. The DON confirmed Resident 15 choked on crackers while eating them in her room and was transferred to hospital. The DON stated if Resident 15's behavior of grabbing snacks from the nursing station was identified on 3/8/24, the choking incident on 3/24/24 was avoidable. During an interview on 6/10/24 at 12:43 p.m. with the Medical Director (MD), the MD stated, Resident 15 was on a puree nectar thickened diet when she choked on crackers. The MD also stated this incident was avoidable. The MD further stated, Resident 15 had enteral feeding after the incident, and it had changed Resident 15's quality of life. Therefore, the Department determined the facility failed to ensure a safe environment when Resident 15 had access to, and consumed, restricted food on 3/24/24 and choked. This failure put Resident 15 at risk for death due to choking and resulted in her hospitalization on 3/24/24. This violation presented an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 15 and affected Resident 15's quality of life when the resident had to rely solely on tube feeding for nutritional needs resulting in an A citation.