Other·October 20, 2023

The following reflects the findings of the California Department of Public Health during the investigation of complaint. Complaint number CA00858864. Representing the Department, HFEN # 42943 HFEN # 43261 HFEN # 43454 B citation was written. F803 Menus Meet Res Needs/Prep in Advance/Followed §483.60(c) Menus and nutritional adequacy. Menus must- §483.60(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines; §483.60(c)(3) Be followed; 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. On 09/01/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct a complaint investigation regarding roaches in the facility. The facility failed to ensure Resident 1 who had diagnoses including dysphagia (inability to chew or difficulty swallowing) and at risk for choking received a diet in the correct form. As a result, on 9/3/2023 at 5:24 p.m. Resident 1 was given a regular consistency diet (no food consistency/texture restrictions) instead of a prescribed puree diet (diet used in the dietary management of dysphagia with the food prepared moist, smooth, cohesive [sticking together] with no water separation and with consistency of a pudding). Resident 1 started to eat the regular consistency diet when the surveyor intervenes. During a review of Resident 1's Admission Record, indicated the facility admitted Resident 1 on 8/14/2023, with diagnoses including acute kidney failure (a condition in which the kidneys suddenly cannot filter waste from the blood), malnutrition (lack of sufficient nutrients in the body) and dysphagia. During a review of Resident 1's Physician's Order (PO), dated 8/16/2023, PO indicated an order for speech therapy (ST) evaluation and treatment of dysphagia for plan of care including oral motor exercises, safe swallow strategies, ongoing diet texture analysis with trial by mouth, and caregiver education and training daily five times per week for four weeks. During a review of Resident 1's Speech Therapy (ST - is the assessment and treatment of communication problems and speech disorders) Care Plan dated 8/16/2023, indicated Resident 1 required speech therapy related to dysphagia to reduce risk of aspiration. During a review of Resident 1's History and Physical (H&P), dated 8/17/2023, the H&P indicated Resident 1 does not have the capacity to make decisions. During a review of Resident 1's Minimum Data Set (MDS-a standardized assessment and care-screening tool), dated 8/18/2023, indicated Resident 1 required one-person physical assist from staff for activities of daily living (ADLs-bed mobility, transfers, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene). MDS also indicated Resident 1 had signs and symptoms of swallowing disorder due to coughing or choking during meals or when swallowing medications. The nutritional approach indicated Resident 1 to have a mechanically altered (require change in texture of food/liquids such as puree food and thickened liquids) diet. During a review of Resident 1's Nutrition Risk Care Plan dated 8/21/2023, indicated Resident 1 was at risk for nutrition deficit (lack of sufficient nutrients in the body) secondary to swallowing deficit. The goal indicated Resident 1 to be able to tolerate diet without chewing and difficulty swallowing. The care plan further indicated to assist Resident 1 with meals and to provide diet as ordered. During a review of Resident 1's Nutritional Assessment document, dated 8/21/2023, indicated Resident 1 was on a puree diet with nectar thickened (easily pourable fluid designed for people with difficulty swallowing) liquid and no ST evaluation changes to the plan of care for Resident 1. During a review of Resident 1's Physician's Order, dated 8/23/2023, indicated a diet order of fortified (food to which extra nutrients have been added), puree texture, nectar thick consistency and with no added salt (NAS) diet. During a concurrent observation and interview on 9/3/2023 at 5:24 p.m., inside Resident 1's room, Resident 1 was observed chewing (food). A dinner tray was observed on Resident 1's bedside table with regular consistency diet of chicken salad, sliced peaches, green beans and slightly touched (consumed/ eaten) baked beans. Surveyor requested Resident 1 to stop eating until a facility staff comes in. During a concurrent observation and interview with LVN 2 on 9/3/2023 at 5:25 p.m., surveyor requested LVN 2 to check on Resident 1's tray. LVN 2 verified Resident 1's current tray was a regular and stated, "Resident 1 should not have a regular diet if the diet order is puree." During a concurrent interview and record review with Registered Nurse 1 (RN 1), on 9/3/2023 at 5:26 p.m., physician's order for Residents 1, dated 8/23/2023, was reviewed. The physician's order indicated Resident 1 to have puree diet. RN 1 verified the physician's orders and stated that Resident 1 had received wrong dinner meal. RN 1 also stated it is important to check a resident's meal tray ticket and to make sure the meal was for right resident, right diet order and right meal consistency prior to serving the meal tray to a resident. During an interview with Dietary Director (DD) on 9/3/2023 at 6:36 p.m., DD stated and verified that on 9/3/2023, all residents' meals were checked during dinner and that all meals were prepared using residents' meal tray tickets to make sure the right diet order was served to the right resident. DD also stated nurses need to check the meals prior to serving to the resident. During an interview with CNA 1 on 9/3/2023 at 6:39 p.m., CNA 1 stated she served the meal tray to Resident 1. CNA 1 stated she was assigned to Resident 1 and that it was her first time to provide care to Resident 1. CNA 1 confirmed and stated resident meal tray ticket are placed on top of the meal container. CNA 1 stated and verified that she did not need to check in with the LN prior to serving the dinner meal for Resident 1. During an interview with the DON on 9/3/2023 at 6:51 p.m., the DON stated upon finding out what happened to Resident 1, she checked on Resident 1's meal tray ticket in Resident 1's bathroom trash can. The DON stated CNA 1 must have accidentally switched Resident 1's meal tray with Resident 8's meal tray. The DON stated, "it was important that facility staff gives the right diet order to the residents due to Resident 1's high risk for aspiration and possibly choking when eating a regular diet meal." During an interview with the Speech Therapist 1 (ST 1), on 9/5/2023 at 1:14 p.m., ST 1 stated and verified ST treatment for Resident 1. ST 1 also stated and confirmed Resident 1 was at risk for aspiration. During a review of the facility's policy and procedures (P&P) titled, "Diet Tray Card," reviewed on 7/18/2023, P&P indicated, "The diet card's primary purpose is to provide caregivers with mealtime information." During a review of the facility's P&P titled, "Tray Identification," reviewed on 7/18/2023, P&P indicated, "Nursing staff shall check each food tray for the correct diet before serving the residents." During a review of the facility's P&P titled, "Dysphagia Diet: Puree," reviewed on 7/18/2023, indicated, "Puree food is more easily swallowed and prevents aspiration." During a review of the facility's P&P titled, "Nutritional Considerations for Dysphagia Management," reviewed 7/18/2023, P&P indicated, "The goal of the dysphagia diet is to maintain optimal nutritional status while providing foods and beverages that reduce the risks of choking and aspiration." The facility failed to ensure Resident 1 who had diagnoses including dysphagia and at risk for choking received a diet in the correct form. As a result, on 9/3/2023 at 5:24 p.m. Resident 1 was given a regular consistency diet instead of a prescribed puree diet. Resident 1 started to eat the regular consistency diet when the surveyor intervenes. The above violation had a direct relationship to the health, safety, and security of Resident 1.