Other·December 28, 2021

42 CFR § 483.35 - Nursing Services The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e). 42 CFR § 483.35 - Proficiency of nurse aides (c) The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. Findings: The facility failed to provide competent emergency basic life support immediately when one out of three residents (Resident 1) was experiencing a Foreign Body Airway Obstruction (FBAO), a choking episode. Nine out of nine facility staff members, including Certified Nurse Assistants (CNA 1, CNA 2), Licensed Vocational Nurses (LVN 1, LVN 2), Registered Nurse (RN 1), Quality Assurance Director (QAD), Supervising Registered Nurse (SRN), Charge RN (CRN) and Recreation/Activities staff (RA 1), failed to respond as trained with the basic emergency life support intervention. The staff failed to implement the Heimlich Maneuver (a procedure to dislodge an obstruction from a person's windpipe) in a timely fashion while Resident 1 was alert and responsive on 12/31/19. The Heimlich Maneuver was delayed and not performed as trained to Resident 1 during his emergency choking episode. This failure worsened the outcome of the FBAO, contributing to the death of Resident 1. During a review of Resident 1's admission orders written on 9/26/19, it was noted his ordered diet was mechanical soft, chopped meat, and thin liquids, "pts (patient's) preference." Within the doctor's orders, the diet had a few changes while Resident 1 resided at this facility. On 9/27/19 a "magic cup" (a fortified supplement) was ordered once daily. His fluids were changed to nectar thick liquids on 10/4/19 at 11:45 AM. On 10/9/19, the "magic cup" was increased to three times daily. On 10/30/19, an order to add butter and gravy to foods as appropriate (for weight gain) was made. During a record review of Resident 1's Resident Care Plan (Speech Therapy), dated 9/26/19, it indicated that PEG tube feedings (direct feeding into the stomach via a tube inserted through the abdominal wall) and N/G tube feedings (nasogastric tube feeding into the stomach via a tube in the nose) were both refused. The record indicated Resident 1 had severe dysphagia and moderate-severe dysarthria (difficult or unclear articulation of speech that is otherwise linguistically normal), and mild to moderate cognitive/linguistic deficits (relationship between language and the mind). This document also indicated, "alteration in nutrition due to swallowing difficulty," and his "inability to eat independently." In his care plan, it was written on 9/26/19 that the facility would "provide assistance as indicated." Resident 1 was being assisted with eating his meal when he choked. During a review of Resident 1's medical record, the Minimum Data Set (MDS - an assessment tool) dated 10/2/19, described Resident 1 as a 69-year-old male, admitted on 9/26/19 to the facility. Resident 1's diagnoses, as listed in the MDS's Care Area Assessment (CAA) included secondary progressive multiple sclerosis (MS - a genetic disease indicated by progressive weakness and loss of muscle mass), end stage, with oral pharyngeal dysphagia (difficulty swallowing). Section K of the MDS, the Swallowing and Nutritional Assessment, indicated that Resident 1 had shown no signs or symptoms of a possible swallowing disorder since his admission, or within 7 days of the assessment. A record review of his weight was completed with the document titled, Weekly/Monthly Weight log, which showed Resident 1's admission weight was 108.4 pounds on 9/26/19 and he measured 5 feet 9.5 inches tall. Three months later on 12/31/19, his weight had increased to 122.2 pounds. A record review of the document titled, Informed Consent Against Medical Advice to Follow Prescribed Modified Diet, was performed. This document indicated he was ordered an NPO (nothing by mouth) diet due to his medical diagnosis of severe Oral Pharyngeal Dysphagia (difficulty swallowing). During an interview with CNA 1 on 1/29/20 at 8:15 AM, CNA 1 stated on 12/31/19, while being assisted with eating his lunch meal in bed, Resident 1 began to choke. He was alert and responsive at the time. He raised his arms to his chest and hit the button to set off his personal alarm which sent alarms to the nursing station. CNA 1 noted his choking, and she pushed the resident alarm on the wall near the bed followed by a "Code Blue alarm" (an alarm to notify other staff members a life-threatening emergency was occurring and signaled the location at the nursing station), both of which sent alarms to the nursing station. Review of an Incident Report dated 12/31/19 at 12:00 p.m., corroborated this description. CNA 1 ran out in the hall to get assistance and quickly returned back into Resident 1's room. During an interview with CNA 1 on 2/4/20 at 11:30 AM, she clarified that while feeding Resident 1 his lunch, the head of the bed was elevated to approximately a 45-degree angle. Resident 1 threw up immediately when he started to choke. CNA 1 was in the room for 2-3 minutes after the nurses (LVN 1 and SRN 1) came in. She did not witness them attempting to perform the Heimlich Maneuver (sudden strong pressure applied on the abdomen between the naval and rib cage to dislodge an obstruction from a person's windpipe) during that time. She stated Resident 1 was fully conscious while she was with him. CNA 1 stated she never attempted to clear Resident 1's airway. She stated she went to get the assistance of someone with "more medical knowledge." On 2/3/20, at 9:05 AM, during observation of a facility video recording showing Resident 1's room from the hallway at the facility, recorded on 12/31/19 with a time stamp of 12/31/19 at 12:17 PM, CNA 1 exited and quickly returned back into the room. A recap of a video timeline titled, Camera 365 (Unit) Resident 80 - Review (undated), presented at the time of viewing, showed she then exited the room again at 12:18 PM. RN 1 and LVN 1 ran in at 12:18 PM, and CNA 1 brought an emergency cart at 12:19 PM. LVN 1 and LVN 2 entered the room with more equipment (the second crash cart) at 12:20 PM. RA 1 entered the room at 12:22 PM. SRN and CRN responded to room subsequently. This time stamp varied from the time mentioned in interviews and the timeline presented by the QAD. During an interview with RN 1 on 2/4/20 at 1:40 PM, RN 1 stated she heard a CNA call out for assistance, "He needs help. He choked! He choked!" RN 1 stated, "I yelled to (QAD) to get the crash cart. When I arrived in the room, he was unresponsive, and the head of the bed was up. I tapped on his chest trying to get a cough. I went to the other side of the bed and lowered the bed. I made a sweeping motion in his mouth." When asked if this was a blind sweep of his mouth, she answered, "Yes it was. I didn't do CPR (Cardiopulmonary Resuscitation). He was a no code... The suction machine finally came in. It clogged up with saliva quickly. A second suction machine arrived with (SRN and the CRN). I clued her in on what I had just done...." When asked if there was someone taking notes, RN 1 responded, "I don't know if anyone was taking notes." She then stated, "I put my finger down his throat to check for a gag reflex. There was none. Then I pulled the tongue forward. Someone mentioned the Heimlich (Maneuver), but I didn't think it was appropriate as he was non-responsive," RN 1 continued, "The head of bed was elevated. (SRN) did the Heimlich Maneuver and then (CRN). They stood on the bedrails and reached around his chest in a sitting position." During a document review of a student instruction manual, utilized by the facility to train staff, titled, Basic Life Support by the American Safety and Health Institute, 2015 Guidelines, the manual indicated, "It is not recommended to use blind finger sweeps to check for foreign objects in the airway." During a review of the clinical record for Resident 1, the IPN (interdisciplinary progress notes) dated 12/31/19 at 1520 (3:20 PM), a late entry for SRN indicated that, "At approx. (sic) 1220 (PM), CNA staff (CNA 1) requested SRN assistance for emergent clinical situation. CNA (CNA 1) reported while assisting Res (Resident 1) with lunch meal, he experienced an episode of possible aspiration [the accidental ingestion of a fluid or solid into the trachea (windpipe) or lungs]. Emergency / Code Blue initiated @ (at) 12:19 (PM). Unit licensed (RN [1] and LVN [1]) staff responded to bedside with emergency cart & suction. SRN & RN from neighboring unit arrived with additional suction as requested. Upon entry to room @ approx. (approximately) 12:21 (PM), Res (Resident 1) was observed to appear cyanotic (bluish tone due to lack of oxygen). RN (RN 1) had implemented use of bag mask for ventilation (a medical device to assist with giving breaths) with O2 (oxygen) and was attempting to perform oral suction with use of yankauer (an oral suctioning tool). No visible secretions captured in canister. Per staff report resident had + (positive) episode of emesis (vomiting) of food partials (sic) @ start of event. RN (RN 1) was observed evaluating for possible lodged food particles & completed finger sweep. Suction (machine) exchanged, and efforts continued. Apical pulse (lower portion of the heart where beats are best heard) auscultated (listened to), present. MD contacted via phone by LVN staff @ approx. 12:21 (PM), notified of situation and EMS (Emergency Medical Services) contacted to assist with additional interventions, as POLST (Physician Orders for Life-Sustaining Treatment) is DNR-S (Do Not Resuscitate - Selective Treatment). Current pulse present. Res (Resident 1) was assisted by clinical staff LVN/RN/SRN in position to perform Heimlich Maneuver. 3-4 thrusts were completed. Initial thrusts expelled audible tone, otherwise unsuccessful @ restoring air exchange. RN (RN 1) exchanged with SRN and performed additional 3-4 thrusts. Res (sic) did not demonstrate respirations, carotid (large artery on the side of the neck used to check for sign of life) pulse absent. [Per undated unsigned facility provided timeline the Heimlich was not performed until 12:20-12:22 where clinical staff performed the Heimlich maneuver twice.] Nsg. (nursing) continued attempts of suction. EMS arrived @ bedside @ 12:30 (PM), reviewed POLST were provided SBAR (Situation, Background, Assessment and Recommendations) report, attempted suction, ambulance arrived at 12:36 (PM). Again, reviewed POLST, SBAR and completed evaluation. Res (sic) without S/S (signs/symptoms) of life - time of death pronounced by EMS (EMS's name) as 12:37 (PM) ..." A document review of the patient's Physicians Order for Life Sustaining Treatment (POLST) dated 9/26/19 was completed. This document indicated Resident 1 chose to be a DNR (do not attempt resuscitation) in section A. Resident 1 chose to select in Section B, "Selective Treatment - goal of treating medical conditions while avoiding burdensome measures. In addition to treatment described in Comfort Focused Treatment, use medical treatment, IV antibiotics, and IV fluids as indicated, do not intubate. May use non-invasive positive airway pressure. Generally, avoid intensive care." Resident 1 selected in section C, "No artificial means of nutrition, including feeding tubes." Section D included information on his end-of-life preferences and a physician signature indicating Resident 1's verbal agreement with the POLST. During an interview with the Director of Staff Development (DSD) on 2/18/20 at 1:20 PM, the DSD stated she was the only Basic Life Support instructor in house at this time. Staff could choose which company they trained with as long as it complied with the American Heart Association's standards. The DSD stated they used American Safety and Health Institute for their training at the facility. She explained that once the airway was obstructed there would be a lack of sound, inability to exchange air and the inability to cough. She continued, "It is then the rescuer acts quickly to do immediate and repetitive abdominal thrusts with their arms around their victim. This process should continue until the foreign body is removed or the patient goes unconscious." She continued, if the patient was unresponsive, they would change interventions to the CPR (cardiopulmonary resuscitation) process as this could expel a foreign object. The DSD said staff would do this even if the patient was a DNR as this was a choking emergency. When asked if this skill was practiced during her class, she responded, "No. We review anatomy of the lungs and diaphragm (the muscle used in breathing) and there is a very graphic film they watch. We have them locate the landmark of where to do the thrusts and have them gently push in and up on themselves. It is too intense of an intervention to practice on one another." A review of the student training book titled, Basic Life Support BLS for Healthcare Providers and Professional Rescuers, by American Safety & Health Institute 2015 Guidelines was completed. The book indicated, "A forceful thrust beneath the ribs and up into the diaphragm can pressurize the air in the chest and pop an obstruction out of the airway. Compression of the chest over the breastbone can also create enough pressure to expel an object.... A person without any air exchange requires your help to survive. Repeated abdominal thrusts, given by standing behind someone and wrapping your arms around him or her have shown to be extremely effective in relieving a severe foreign-body obstruction." The student book indicated the responder is to continue with the Heimlich maneuver until the person can breathe normally or if the person becomes unresponsive, they are then to lower the patient to the floor and begin CPR, starting with compressions... "This is to continue until another BLS provider takes over, the person shows signs of life or you are too exhausted to continue." A record review of the facility staff's trainings verified completion of the Basic Life Support classes were completed by RA 1, CNA 1, CNA 2, LVN 1, LVN 2, RN 1, SRN, CRN, and QAD. These staff were all current in their BLS training. One professional was a certified instructor of BLS. During record review of a document presented by the QAD, an undated and unsigned timeline had been created from various documentation entries, recollections, and the video of the hallway outside of Resident 1's room. This document indicated the interventions to clear the airway began at 12:08 PM. It also indicated that the Heimlich Maneuver was not performed until 12:20 to 12:22 PM. The IPN note dated 12/31/19 at 1520 (3:20 PM) indicated staff provided 2 sequences of 3-4 thrusts several minutes following his loss of consciousness, approximately 12-14 minutes after the choking event began per timeline presented by the QAD. The times varied on the video recording, in interview statements, in progress notes, and within the document presented by the QAD making it difficult to verify the actual times of the events. During a search of the internet at MedlinePlus National Institutes of Health/ U.S. National Library of Medicine at https://medlineplus.gov/ency/article/000049.htm, this site indicated, "A choking person's airway may be blocked so that not enough oxygen reaches the lungs. Without oxygen, brain damage can occur in as little as 4 to 6 minutes. Rapid first aid for choking can save a person's life." A record review of the Patient Care Report (PCR, the emergency response report) from the emergency call center, from 12/31/19, indicated the emergency call came in at 12:27 PM. Emergency Medical Services (EMS) arrived on scene at 12:35 PM. Time of death was called at 12:37 PM. "Call Type" was listed as "Cardiac Arrest / Death." Disposit