Other·August 29, 2023

42 CFR §483.25(d) Accidents (Federal reference number) The facility must ensure that – (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. 42 CFR §483.21(b) Comprehensive Care Plans (Federal reference number) (1) The facility must develop and implement a comprehensive person-centered care plan for each resident. 22 CCR §72311 Nursing Service - General (Title 22 reference) (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. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (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. 42 CFR §483.60(d) Food and drink (Federal reference number) Each resident receives and the facility provides— (3) Food prepared in a form designed to meet individual needs. 22 CCR §72335 Dietetic Service -Food Service (Title 22 reference) (a) The dietetic service shall provide food of the quality and quantity to meet each patient's needs in accordance with the physicians' orders and to meet “The Recommended Daily Dietary Allowance,” the most current edition, adopted by the Food and Nutrition Board of the National Research Council of the National Academy of Sciences, and the following: (3) Patient food preferences shall be adhered to as much as possible and substitutes for all food refused shall be from appropriate food groups. Condiments such as salt, pepper or sugar shall be available at each meal unless contraindicated by the diet order. (7) Recipes for all items that are prepared for regular and therapeutic diets shall be available and used to prepare attractive and palatable meals, in which nutritive values, flavor and appearance are conserved. Food shall be served attractively, at appropriate temperatures with appropriate eating utensils and in a form to meet individual needs. 22 CCR §72311 Nursing Service – General (Title 22 reference) (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 22 CCR §72523 Patient Care Policies and Procedures (Title 22 reference) (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. 22 CCR §72315 Nursing Service - Patient Care (Title 22 reference) (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. 22 CCR §72527 Patients' Rights (Title 22 reference) (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (3) To be fully informed by a physician of his or her total health status and to be afforded the opportunity to participate on an immediate and ongoing basis in the total plan of care including the identification of medical, nursing, and psychosocial needs and the planning of related services. On 7/17/2023, the California Department of Public Health (CDPH) received a facility reported incident (FRI) regarding an allegation of Resident 1’s death. On 7/18/2023, CDPH received a complaint regarding an allegation of Resident 1’s death. On 7/18/2023, CDPH conducted an unannounced visit at the facility. During the investigation, it was discovered Resident 1 had a prior choking episode on 2/16/2023 while receiving a regular texture diet. After the episode, Resident 1 was assessed and evaluated by the Speech Therapist (ST 1) with recommendations for a dysphagia advanced texture diet and to provide one-to-one (1:1) monitoring and supervision while eating. On 7/13/2023, Resident 1 was provided a peanut butter and jelly sandwich and graham crackers and left unsupervised, which led to Resident 1 choking and expiring. The facility failed to: 1. Ensure Resident 1 received a dysphagia (difficulty in swallowing food or liquid) advanced texture diet as recommended by the Speech Therapist ([ST] specialist trained to help people with speech and language problems to speak more clearly) and prescribed by the physician. 2. Provide one-to-one (1:1- when an individual staff member is assigned to directly supervise no more than one resident and the staff shall stay within very close proximity to ensure constant supervision and immediate intervention or assistance if needed for safety reasons) supervision for Resident 1, as indicated by ST 1’s assessment/recommendations after a choking episode on 2/16/2023. 3. Develop a care plan addressing Resident 1’s risk for aspiration (occurs when food, drink, or foreign objects are breathed into the lungs), after a choking episode on 2/16/2023, to reflect an advanced texture diet based upon the physician order and ST recommendations. 4. Follow the physician order updating Resident 1’s diet to an advanced texture diet. As a result of these failures, Licensed Vocational Nurse (LVN) 1 provided Resident 1 a peanut butter and jelly sandwich and graham crackers and failed to provide supervision while the resident was eating on 7/13/2023 at 8:10 p.m. Resident 1 was later found unresponsive and cyanotic (bluish or grayish color of the skin, nails, lips, or around the eyes), by Certified Nurse Assistant (CNA) 1 on 7/13/2023 at 8:20 p.m. There were food particles in his mouth and he was subsequently pronounced deceased at 8:43 p.m. on 7/13/2023. A review of Resident 1's Admission Record (face sheet) indicated Resident 1, was a 74 year old male, who was originally admitted to the facility on 3/1/2022, and last readmitted on 4/25/2023 with diagnoses that included cerebral infarction (a stroke, disrupted blood flow to the brain causing parts of the brain become damaged or die) with dysphagia (difficulty swallowing foods or liquids), aphasia (a language disorder that affects a person's ability to communicate), and dementia (a term for a range of conditions that affect the brain's ability to think, remember, and function normally). A review of Resident 1’s History and Physical Examination (H&P), dated 4/27/2023, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 5/10/2023, indicated the resident had severely impaired cognition (ability to think and reason) for daily decision making. The MDS indicated Resident 1 required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) with eating, and extensive assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility, transfer, dressing, toilet use and personal hygiene. A review of Resident 1’s Physician Order, dated 2/17/2023, indicated Resident 1’s diet was changed from regular texture to dysphagia advanced texture (foods that hard to chew are chopped, ground, shredded, cooked, or altered to make them easier to chew and swallow and any foods that are very hard, sticky, chewy or crunchy should be avoided), after a choking episode on 2/16/2023. A review of Resident 1’s Speech Therapy Treatment Encounter Note (ST Note), dated 2/17/2023, indicated Resident 1 had a change of condition due to choking and the Heimlich maneuver (a first aid procedure used to treat upper airway obstructions [or choking] by foreign objects) was performed. The ST Note indicated Resident 1 demonstrated holding food in the mouth/cheeks or residual food in the mouth after meals and coughing or choking during meals. A review of Resident 1’s ST Note, dated 2/24/2023, indicated Resident 1 was observed with a dysphagia advanced meal tray and the resident responded well to verbal prompts to slow pace and finished bites before taking another. The ST Note indicated Resident 1 continued to benefit from “One-to-One supervision for verbal prompts.” The ST Note also indicated Resident 1 and nursing staff were made aware and agreed. During a telephone interview on 7/18/2023, at 10:54 a.m., with CNA 1, CNA 1 stated at approximately 8:20 p.m. on 7/13/2023, when she was going into the room adjacent to Resident 1’s room, she saw that Resident 1’s upper body was lying on the foot of the bed with his face on the bed and feet on the floor. CNA 1 stated she called Resident 1’s name several times, but Resident 1 did not respond or move. CNA 1 stated she called for help immediately, then, LVN 1 and Registered Nurse (RN) 1 came to check on Resident 1. CNA 1 stated LVN 1 turned Resident 1 over and swept the resident’s mouth with her finger. During a telephone interview on 7/18/2023, at 1:44 p.m., with LVN 1, LVN 1 stated at approximately 8:00 p.m. on 7/13/2023, she passed by Resident 1’s room and saw the resident sitting on his bed and pulling on the bed curtain, making a grunting sound. LVN 1 stated she asked Resident 1 if he was hungry and would like to have something to eat. Resident 1 nodded and grunted as a yes. LVN 1 stated she grabbed a peanut butter and jelly sandwich, some graham crackers and a house shake from the bedtime snack tray at the nursing station and provided the food items to Resident 1 without checking Resident 1’s diet order at 8:10 p.m. on 7/13/2023. LVN 1 stated the peanut butter and jelly sandwich, graham crackers and house shake were not labeled with any resident’s name, and the snacks and food items were pre-prepared in case if any resident would like additional bedtime snacks. LVN 1 stated she thought Resident 1 was on a regular texture diet. LVN 1 stated she assisted Resident 1 to sit at the corner of the foot of the bed and placed his bedside tray table in front of him. LVN 1 stated she observed Resident 1 take a few bites of the peanut butter and jelly sandwich and left the room to tend to another resident. LVN 1 stated at approximately 8:20 p.m. on 7/13/2023, she heard CNA 1 call for help. LVN 1 stated she went to Resident 1’s room and saw Resident 1 was facing down on the bed and unresponsive. LVN 1 stated she checked Resident 1’s pulse, patted his back and saw him turning blue. LVN 1 stated there were food particles in Resident 1’s mouth, so she swept Resident 1’s mouth with her finger and removed a spoonful of mashed food from his mouth. LVN 1 stated emergency response was requested at approximately 8:25 p.m. and paramedics arrived at the facility at 8:36 p.m. on 7/13/2023. LVN 1 stated the paramedics pronounced Resident 1 expired at 8:43 p.m. on 7/13/2023. LVN 1 stated Resident 1 tended to eat fast, and she was aware that he required supervision while eating, but she did not stay to supervise Resident 1 finishing his snack and she did not inform other staff to supervise Resident 1 while eating the snack. LVN 1 stated after she left the room, Resident 1 was eating without any supervision from the staff. LVN 1 stated a peanut butter and jelly sandwich, and graham crackers were not considered as appropriate for Resident 1’s dysphagia advanced diet. LVN 1 stated Resident 1 was at risk for aspiration, and she should have checked Resident 1’s diet order and provide supervision during eating. A review of LVN 1’s Written Declaration, dated 7/18/2023, at 3:30 p.m., indicated LVN 1 provided a peanut butter and jelly sandwich and graham crackers to Resident 1 without checking the diet order and did not provide supervision to Resident 1 while eating at 8:10 p.m. on 7/13/2023. During an interview on 7/18/2023, at 4:33 p.m., with ST 1, ST 1 stated she saw Resident 1 on 2/17/2023 and Resident 1 was on a modified diet, for example, chopped food items, ground meat, rice, and cut pasta, but no toasted bread. ST 1 stated she did not evaluate if Resident 1 could tolerate a peanut butter and jelly sandwich without supervision. ST 1 stated she recommended 1:1 supervision for verbal prompts during meals and Resident 1 would be at a minimal to moderate risk for aspiration and choking without supervision. ST 1 stated it would not be safe for Resident 1 to eat a whole peanut butter and jelly sandwich. During a telephone interview on 7/19/2023, at 11:22 a.m., with CNA 2, CNA 2 stated Resident 1 had an episode of choking some time ago (2/16/2023). CNA 2 stated after that incident, Resident 1 required staff to supervise and remind him to eat slowly during meals because he liked to put a lot of food in his mouth and eat fast. CNA 2 stated it was important to check Resident 1’s diet order to prevent choking and ensure his safety. During an interview on 7/19/2023, at 12:19 p.m., with the Registered Dietitian (RD), the RD stated Resident 1 was on a dysphagia advanced diet. The RD stated Resident 1 should have received food that had a soft texture and was chopped. The RD stated graham crackers were not allowed for residents on a dysphagia advanced diet. The RD stated the facility had creamy peanut butter in stock on 7/13/2023, so the peanut butter and jelly sandwich which was provided to Resident 1 was made from the creamy peanut butter. The RD stated a ST evaluation was required to evaluate if a resident could tolerate creamy peanut butter before providing a peanut butter and jelly sandwich. The RD stated LVN 1 should have checked Resident 1’s diet order and made sure each food item provided to Resident 1 was consistent with the food texture as the physician’s diet order. During an interview on 7/19/2023, at 1:59 p.m., with the Director of Nursing (DON), the DON stated Resident 1 had a choking episode while eating dinner in his room on 2/16/2023, then, his diet was changed from regular texture to a dysphagia advanced diet on 2/17/2023. The DON stated the ST evaluation was ordered and the ST initiated the evaluation on 2/17/2023. The DON stated ST 1 made recommendations on 2/24/2023, indicating Resident 1 was on dysphagia advanced diet and required 1:1 supervision with verbal prompts to Resident 1 while eating. The DON stated the facility placed Resident 1 on the “Eating with Supervision” List which was located at each nursing station to alert the staff that Resident 1 required supervision while eating. The DON stated through the facility’s investigation, the facility found LVN 1 provided a peanut butter and jelly sandwich to Resident 1 without checking Resident 1’s diet order and left Resident 1 to eat without supervision in the room at 8:10 p.m. on 7/13/2023. The DON stated LVN 1 should have checked Resident 1’s diet order to make sure each food item was appropriate for Resident 1’s dysphagia advanced diet, and LVN 1 should have followed the ST’s recommendation to provide supervision to Resident 1 while eating. The DON stated LVN 1’s action placed Resident 1 at risk for aspiration and choking. During a concurrent interview and record review, on 7/19/2023, at 3:00 p.m., with the DON, Resident 1’s care plans were reviewed. Resident 1’s care plans indicated there was no