Other·January 19, 2023

The following reflects the findings of the California Department of Public Health during the investigation of entity reported incident CA00797582. Representing the Department: Health Facilities Evaluator Nurse, 43763 State A Citation issued F689 §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The patient environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each patient receives adequate supervision and assistance devices to prevent accidents. § 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. (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. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. § 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. On 8/11/2021 at 8:20 a.m., an unannounced visit was made at the facility to investigate a complaint regarding quality of care and treatment and patient safety. As a result of the investigation, the Department determined that the facility failed to: 1. Ensure safety for Resident 1 when Resident 1's physician ordered diet was not followed; 2. Ensure that Resident 1's dietary profile which required staff supervision while eating was not provided; 3. Follow the facility's policy and procedure on "Nutrition Management of Dysphagia Mechanical," dated 2020, when CNA C provided a peanut butter and jelly sandwich to Resident 1 which resulted in Resident 1 choking, transferred to the general acute care hospital (GACH), and ultimately pronounced dead as a result of choking on food. As a result of these failures, Resident 1 was sent to the GACH to have a large food bolus removed via laryngoscopy (a procedure where a tube is in the throat and allows doctors to remove foreign objects) into the pharynx (the throat). Resident 1 suffered hypoxia (lack of enough oxygen) which induced a cardiac arrest (sudden unexpected loss of heart function), and neurological damage (brain damage). Resident 1 expired 5/1/2022 due to complications of choking on food bolus. Findings: Review of Resident 1's face sheet, dated 7/21/2019, indicated Resident 1 had a history of Parkinson's Disease (a disorder of the central nervous system that affects movement and can cause difficulty swallowing), dysphagia (difficulty in swallowing), oropharyngeal phase (swallowing problems that occur in the mouth and/or throat), and diabetes (a chronic condition that affects the way the body processes sugar). During an interview with licensed vocational nurse A (LVN A), on 8/11/2022 at 10:27 a.m., LVN A confirmed Resident 1's face sheet indicated Resident 1 had a history of Parkinson's Disease, dysphagia, and diabetes. Record review of Resident 1's Speech Language Pathology (SLP) Evaluation and Plan of Treatment," dated 5/29/2019, indicated Resident 1 had poor self-monitoring skills, decreased safety awareness and at risk for aspiration (when food or liquid enter the airway) and choking. During an interview with LVN A, on 8/11/2022 at 10:27 a.m., LVN A confirmed Resident 1's speech therapy "SLP Evaluation and Plan of Treatment," dated 5/29/2019, indicated Resident 1 had poor self-monitoring skills, decreased safety awareness and at risk for aspiration, and choking. Review of Resident 1's "dietary profile," dated 12/20/2021, indicated Resident 1 required supervision under "eating assistance." During an interview with LVN A, on 8/11/2022 at 10:27 a.m., LVN A confirmed Resident 1's "dietary profile," dated 12/20/2021, required supervision under "eating assistance." Review of Resident 1's "nutritional risk assessment," dated 12/29/2021, indicated Resident 1 required supervision while eating, had chewing and swallowing problems, and fed self with verbal cues. During an interview with LVN A, on 8/11/2022 at 10:27 a.m., LVN A confirmed Resident 1's "nutritional risk assessment," dated 12/29/2021, indicated Resident 1 required supervision while eating, had chewing and swallowing problems, and fed self with verbal cues. During an interview with the Director of Rehabilitation Services (DRS), on 8/11/2022 at 3:37 p.m., DRS confirmed Resident 1 had Parkinson's Disease and muscle weakness and stated he required reminders to swallow and chew and to check for pocketed food (storing food inside the mouth and not swallowing) at times. The DRS stated these all put him at risk for choking. Review of Resident 1's Minimum Data Set (MDS; tool used to assess residents), dated 6/17/2021, indicated Resident 1 required staff supervision or touching assistance with verbal cues, touching, and steadying while eating. During an interview with the Minimum Data Set Coordinator (MDSC), on 8/11/2022 at 4:11 p.m., the MDSC confirmed Resident 1's MDS indicated Resident 1 required staff supervision or touching assistance with verbal cues, touching and steadying while eating. Review of Resident 1's physician orders, dated 2/24/2019, indicated Resident 1 was on a fortified (nutrients are added to food to improve nutrition) diet that was mechanical altered level two texture (moist, mechanically altered or easily mashed and must not be sticky or bulky). During an interview LVN A, on 8/11/2022 at 10:27 a.m., LVN A confirmed Resident 1's physician orders, dated 2/24/2019, indicated Resident 1 was on a fortified diet that was mechanical altered level two texture. During an interview with the Dietary Supervisor (DS), on 8/11/2022 at 2:38 p.m., the DS indicated for the mechanical altered level two texture diets that the food must be easily mashed and that, for this diet, the diet excludes difficult to chew foods, sticky foods, and bulky foods. Review of the facility's diet manual section "Nutrition Management of Dysphagia Mechanical," dated 2020, indicated for the dysphagia mechanical diet, foods must not be sticky or bulky and that they would increase the risk of airway obstruction if sticky or bulky. The manual further indicated bread and peanut butter were on the "avoid" list and not on the "allowed" list for this diet and indicated that should be followed. During an interview with the Dietary Supervisor (DS), on 8/11/2022 at 2:38 p.m., she confirmed the facility's diet manual section for the dysphagia mechanical diet indicated foods must not be sticky or bulky and that they would increase the risk of airway obstruction if sticky or bulky. She confirmed the manual further indicated the bread and peanut butter were on the "avoid" list for Resident 1 and the avoid list should have been followed. Record review of Resident 1's "Change of Condition," dated 2/17/2022 at 4:45 a.m., indicated Resident 1 was in a wheelchair in front of the nurse's station. The note indicated he was given a sandwich and an ensure milk (nutritional drink that provides protein). During a phone interview with the Certified Nursing Assistant C (CNA C), on 8/12/2022 at 9:28 a.m., CNA C stated Resident 1 woke up early that morning on 2/17/2022. CNA C stated she assisted Resident 1 into a wheelchair and brought Resident 1 in front of the nurse's station. CNA C stated she then gave Resident 1 a peanut butter and jelly sandwich. CNA C stated she did not know Resident 1's diet order or if Resident 1 could have peanut butter and jelly sandwiches. CNA C stated she usually asks the nurse if she could give a sandwich to a resident, but this time she did not ask the nurse. CNA C stated she did not ask the nurse because she has given Resident 1 sandwiches in the past and she stated she knows him. CNA C stated she did not observe or supervise while Resident 1 ate the sandwich. CNA C stated shortly after giving the sandwich she was walking by and saw Resident 1's "...head was down, so we assumed he choked." CNA C stated Resident 1's nurse did the Heimlich maneuver (a first aid procedure for dislodging an obstruction from person's windpipe) with no results. CNA C stated emergency services were called and they told the nurse to initiate Cardio-Pulmonary Resuscitation (CPR, a medical procedure involving repeated of resident's chest compression to restore the blood circulation and breathing). During a phone interview with Registered Nurse B (RN B) on 8/12/2022 at 7:46 a.m., RN B stated she remembered Resident 1 and the incident on 2/17/2022. RN B confirmed CNA C brought Resident 1 to the nurse's station and gave him a sandwich. RN B stated "...I was passing my meds and he looked okay when I passed by." During a phone interview with RN B on 8/12/2022 at 7:46 a.m., RN B stated Resident 1 ate more than half of the sandwich and stated she did not know if Resident 1 could have sandwiches or not. RN B confirmed nursing should follow the diet orders. RN B stated the CNA C was supposed to check with the nurse prior to giving any food. She stated CNA C did not ask her prior to giving Resident 1 a sandwich. She stated she told CNA C to check with her before giving food to any resident. RN B stated she was administering medications to other residents during this time and was not directly supervising Resident 1 as he was eating. Record review of Resident 1's "Change of Condition," dated 2/17/2021, for shortness of breath and unresponsiveness, indicated at 5:15 a.m. CNA C found the resident head facing down and unresponsive with labored breathing. The note indicated emergency services were notified and the Heimlich maneuver (first aid procedure for when someone is choking and done to dislodge food from throat or windpipe) was performed on Resident 1 with no results. Resident 1 was placed on the floor and at 5:30 a.m. Cardio-Pulmonary Resuscitation (CPR; emergency procedure with chest compressions and artificial breathing to preserve intact brain function) was initiated. At 5:40 a.m. Resident 1 was transferred to a nearby hospital via ambulance. During a phone interview with RN B on 8/12/2022 at 7:46 a.m., RN B stated CNA C saw Resident 1's head down and "...he was not responding, so I immediately did the Heimlich maneuver." RN B stated she did so because Resident 1 was eating, and she believed Resident 1 had choked. RN B stated she then moved Resident 1 to the floor and emergency services indicated she start CPR, so she did. During a phone interview with the Registered Dietician (RD), on 8/11/2022 at 3:04 p.m., she indicated a peanut butter and jelly sandwich would be excluded from Resident 1's diet because of the peanut butter and bread and stated it would increase his risk of choking. She confirmed the facility manual has further information on the allowable food items for the mechanical altered level two diet. During a phone interview with the Medical Doctor (MD), on 9/2/2022 at 12:39 p.m., the MD stated Resident 1 had weakness and was not able to communicate his needs very well. The MD confirmed Resident 1 had difficulties eating and was evaluated for the appropriate diet and based off the evaluation needed a mechanical level two diet. MD stated he was not aware Resident 1 was given a peanut butter and jelly sandwich and stated they should not have given this. MD also stated he expected the facility should have followed the physician diet order and the physician diet order was a part of the plan of care for Resident 1. Record review of the acute hospital's admission note, dated 2/17/2022, indicated Resident 1 was brought into the hospital with a hypoxia (lack of oxygen) induced cardiac arrest in the setting of an aspiration event. Record review of the local hospital's emergency department note, dated 2/17/2022, indicated Resident 1 required a "foreign body removal from orifice (an opening in the body)" and indicated a "...large food bolus that was a concretion (a hard solid mass) removed from the oropharynx (part of the throat at the back of the mouth) that was occluding (blocking) the airway as well as the esophagus (canal that connects throat to stomach)." The note indicated the large food bolus was removed by laryngoscopy (a procedure where a tube is in the throat and allows doctors to remove foreign objects) into the pharynx (the throat). Record review of the local hospital's discharge note, dated 3/29/2022, indicated Resident 1 had pulseless electrical activity (when there is no pulse, and the heart has stopped due to cardiac arrest) due to choking on food. The note indicated Resident 1 had poor neurological status due to this anoxic (lack of oxygen) brain injury. Review of Resident 1's death certificate, which listed 5/1/2022 as the date of death, listed the immediate cause of death as "...complications of choking on food bolus." The death certificate further indicated the date of injury was 2/17/2022, that the injury occurred in the skilled nursing facility, and that the injury was the result of choking on food. Review of facility policy "Diet Orders," dated 6/15/2018, indicated the diet order was based on resident assessment and any health diseases or conditions. Policy further indicated that consistency altered diets may not be waived or changed without assessment and order change. Record review of facility policy "Physician Orders, "dated 3/22/2022, indicated the licensed nurse was responsible for implementing the orders for the resident. As a result of the investigation, the Department determined that the facility failed to: 1. Ensure safety for Resident 1 when Resident 1's physician ordered diet was not followed; 2. Ensure that Resident 1's dietary profile which required staff supervision while eating was not provided; 3. Follow the facility's policy and procedure on "Nutrition Management of Dysphagia Mechanical," dated 2020, when CNA C provided a peanut butter and jelly sandwich to Resident 1 which resulted in Resident 1 choking, transferred to the general acute care hospital (GAC), and ultimately pronounced dead as a result of choking on food. As a result of these failures, Resident 1 was sent to the GACH to have a large food bolus removed via laryngoscopy (a procedure where a tube is in the throat and allows doctors to remove foreign objects) into the pharynx (the throat). Resident 1 suffered hypoxia (lack of enough oxygen) which induced a cardiac arrest (sudden unexpected loss of heart function), and neurological damage (brain damage). Resident 1 expired 5/1/2022 due to complications of choking on food bolus. These violations jointly, separately or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.