Health inspection·January 25, 2023

F689 42 CFR § 483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. On 12/8/2022, the California Department of Public Health made an unannounced visit to the facility to investigate a Facility-Reported Incident (FRI) regarding quality of care, resident safety and death. The facility failed to ensure Resident 1 was free from neglect (the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress), was provided the diet texture ordered by the physician that was first verified with a licensed nurse, and was supervised and assisted with eating. For Resident 1, who required a soft and bite-size texture diet (easy to chew and swallow) due to risk of aspiration (when food, liquid, or other material accidentally enters a person's airway and lungs), Certified Nursing Assistant 1 (CNA 1) served a salad provided by Dietary Aide 1 (DA 1) which contained crispy, dry, and hard to chew and swallow ingredients. DA 1 knew the salad did not follow Resident 1’s prescribed diet and CNA 1 did not ask a licensed nurse to verify the salad was safe to give to Resident 1. As a result, on 12/2/2022, at 12:35 p.m., Resident 1 choked (stopped breathing because something was blocking the throat and airway). Resident 1 required abdominal thrusts (also called the Heimlich maneuver, a technique in first aid to dislodge a foreign body in a person's airway by applying sudden upward pressure on the upper abdomen) and cardiopulmonary resuscitation (CPR - an emergency life-saving procedure done when someone's breathing, and heartbeat stops). Resident 1 was revived (regained life) and transferred to General Acute Care Hospital 1 (GACH 1). While at the GACH, the resident coded (abrupt loss of heart function) multiple times, required intubation (placement of a flexible plastic tube into the trachea [a tube structure in the body that carries air] to maintain an open airway), and subsequently expired (died) on 12/4/2022. A review of Resident 1's Admission Record indicated the facility initially admitted Resident 1, an 87-year-old male, on 5/6/2022 with a readmission dated 6/10/2022, with diagnoses that included dysphagia (difficulty swallowing), chronic obstructive pulmonary disease (COPD - a lung disease that causes obstructed airflow from the lungs, making it hard to breathe), and type 2 diabetes mellitus (the body's inability to regulate sugar levels in the blood). A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-planning tool), dated 11/12/2022, indicated Resident 1 had moderately impaired cognition (ability to think and make decisions) and required one-person physical assistance. The MDS also indicated Resident 1 was on a mechanically altered diet (a type of diet where the texture is modified to help people who have difficulty with chewing and swallowing). A review of Resident 1’s Speech Therapist (ST or SLT, a licensed professional who assesses, diagnoses, and treats speech disorders and swallowing problems) Evaluation and Plan of Treatment note, dated 6/14/2022 (last day of ST treatment), included in the recommendations to provide Resident 1 close supervision for oral intake (while eating). A review of the Physician's Order for Resident 1, dated 6/14/2022, indicated to give the resident a no salt added, and soft and bite-size texture, regular consistency diet. A review of Resident 1's lunch Tray Card for 12/2/2022 indicated the resident was on a no-added salt, soft and bite-sized texture, thin liquids diet. A review of Resident 1's Change of Condition Evaluation, dated 12/2/2022, indicated at 12:35 p.m., Resident 1 was eating his lunch and choked. Resident 1 became cyanotic (a bluish coloration of the skin caused by lack of oxygen), staff initiated the Heimlich maneuver and suctioning (the use of suction to remove debris or body fluids from an airway) interventions, called 911 (telephone number to contact medical emergency services [EMS, paramedics]), and paramedics transported Resident 1 to GACH 1. A review of the Employee Corrective Action Notice for DA 1’s personnel file, dated 12/5/2022, indicated on 12/2/2022, DA 1 reviewed Resident 1's diet Tray Card for lunch and noted the resident was on a soft and bite-sized diet but despite reading Resident 1's Tray Card for dietary restrictions, DA 1 provided Resident 1 a “Chef 's Salad” (made of lettuce and other raw vegetables [usually crispy and crunchy] topped with slices of meat [pre-cooked], cheese, croutons [small cubes of toasted or crispy fried bread], and hard-boiled eggs). A review of the facility' s Employee Corrective Action Notice for CNA 1’s personnel file, dated 12/8/2022, indicated on 12/2/2022, CNA 1 obtained a salad for Resident 1 as requested by the resident but failed to follow the facility’s process of having a licensed nurse check the food before serving it to the resident and the salad served to Resident 1 did not follow the diet restriction Resident 1’s physician ordered. During an interview on 12/8/2022 at 2:25 p.m., the Director of Nursing (DON) stated on 12/2/2022, Resident 1 was served, for lunch, food that was not part of his prescribed diet. The DON stated Resident 1 was on a prescribed diet that required soft, bite-sized food, but was served a Chef’s Salad that had raw vegetables and dry croutons. The DON stated Resident 1 had requested for CNA 1 to get him a salad. The DON stated DA 1 provided a Chef's Salad to CNA 1, who then served it to Resident 1 and the resident choked while eating the salad. During an interview on 12/8/2022 at 2:58 p.m., CNA 2 stated she was in the dining room during lunch time on 12/2/2022. CNA 2 stated that around 12:30 p.m., when she was walking around the dining room checking on the residents, she saw Resident 1 coughing, gasping for air, with his hands around his neck, which indicated he was choking. CNA 2 stated she proceeded to perform abdominal thrusts on Resident 1 while screaming for help. CNA 2 stated Licensed Vocational Nurse 1 (LVN 1) came into the dining room and took over the abdominal thrusts and asked CNA 2 to get a suction machine (medical device used to remove obstructions and secretions from the airway). CNA 2 stated on her way to get the suction machine, she asked the receptionist to call 911. CNA 2 stated that by the time she went back to the dining room, Resident 1 was on the floor with staff performing CPR on him. During an interview on 12/8/2022 at 3:40 p.m., the Dietary Manager (DM) stated that when she interviewed DA 1, after Resident 1's choking incident on 12/2/2022, DA 1 admitted giving CNA 1 a Chef's Salad even though she read Resident 1's tray card indicated he was on a soft, bite-sized diet. The DM stated a Chef 's Salad consisted of raw lettuce, raw tomatoes, shredded cheese, pieces of ham, slices of boiled egg and croutons. The DM stated that DA 1 should have known a Chef's Salad was not allowed for a resident on a soft, bite-sized diet since it had hard, crunchy ingredients like the raw lettuce and croutons. The DM stated the raw lettuce and croutons were not safe for a resident on a soft, bite-sized diet. The DM stated if DA 1 had any questions, she should have asked the DM prior to giving the salad to CNA 1. The DM stated serving Resident 1 food items not allowed on his prescribed diet put him at risk for choking. During an interview on 12/8/2022 at 4:10 p.m., CNA 1 stated that during lunchtime on 12/2/2022, Resident 1 informed him he did not like the food served to him and requested a salad. CNA 1 stated he took Resident 1's tray card to the kitchen, presented it to DA 1, and informed DA 1 Resident 1 was requesting a salad. CNA 1 stated that DA 1 looked at the tray card and then handed him a Chef's Salad. CNA 1 stated he brought the salad back to the dining room and served it to Resident 1 without having a licensed nurse check the food to verify the salad prepared was within Resident 1's dietary restriction. CNA 1 stated he understood he bypassed a safety check, but he was just trying to get Resident 1 the food he wanted so that the resident could eat. CNA 1 stated he thought the salad would be okay to serve to Resident 1 because he trusted that DA 1 looked at the tray card to make sure the food given was part of Resident 1's diet. On 12/9/2022 at 4:21 p.m., during an interview, the DON stated the facility had numerous safety protocols in place to ensure residents are served only food that is part of their physician’s prescribed diet. The DON stated DA 1 should have checked the tray card carefully and only provide food that is within Resident 1's dietary restriction. The DON then stated that CNA 1 should have ensured a licensed nurse checked the food before serving it to Resident 1. The DON stated unfortunately DA 1 and CNA 1 bypassed the facility's safety protocols which was neglectful. A review of GACH 1's Discharge Summary Report dated 12/6/2022 indicated that Resident 1 was brought in with respiratory distress (trouble breathing) after being found hypoxic (low levels of oxygen in the body). Resident 1 decompensated (decline in health) after arrival and coded three times before being transferred to the Intensive Care Unit (ICU - a part of a hospital where patients who are extremely ill or very badly injured are looked after constantly). A review of the facility's policy and procedure titled, "Abuse Prohibition and Prevention," revised on 8/2022, indicated the facility prohibits and prevents abuse, neglect, exploitation, misappropriation of property and mistreatment. A review of the facility's policy and procedure titled, "Nutrition Services for All Residents", revised on 10/24/17 indicated that the resident ' s nutritional status and their nutritional needs will be assessed. A nutritional program specific to their needs will be planned and implanted. A review of the facility's policy and procedure titled, "Diet Tray Card," revised 1/2013, indicated the diet card primary purpose is to inform the dietary staff how to assemble the resident's meal tray and provide caregivers with mealtime information. The policy and procedure further indicate that the facility is to ensure that food items served are consistent with tray card information. The facility failed to ensure Resident 1 was free from neglect, was provided the diet texture ordered by the physician that was first verified with a licensed nurse, and was supervised and assisted with eating. For Resident 1, who required a soft and bite-size texture diet due to risk of aspiration, CNA 1 served a salad provided by DA 1 which contained crispy, dry, and hard to chew and swallow ingredients. DA 1 knew the salad did not follow Resident 1’s prescribed diet and CNA 1 did not ask a licensed nurse to verify the salad was safe to give to Resident 1. As a result, on 12/2/2022, at 12:35 p.m., Resident 1 choked. Resident 1 required abdominal thrusts and CPR. Resident 1 was revived and transferred to GACH 1. While at the GACH, the resident coded multiple times, required intubation and subsequently expired on 12/4/2022. These violations, jointly, separately or in any combination, presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result, and a substantial factor in the death of Resident 1.