MANORCARE AT URBANA
Facility I..D. Number: 0027565
600 N. Coler St.
Urbana, IL 61801
Date of Survey: 10/20/00
Notice of Violation: 12/20/00
Complaint Investigation
The facility shall provide a Resident Services Director who is assigned responsibility for the coordination and monitoring of the resident's overall Plan of Care. The Director of Nurses or an individual on the professional staff of the facility may fill this assignment to assure that residents' plans of care are individualized, written in terms of short and long-range goals, understandable and utilized; their needs are met through appropriate staff interventions and community resources; and residents are involved, whenever possible, in the preparation of their Plan of Care.
The facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of the resident, in accordance with each resident's comprehensive assessment and Plan of Care. Adequate and properly supervised nursing care and personal care shall be provided to each resident to meet the total nursing and personal care needs of the resident.
All nursing personnel shall assist and encourage residents so that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that diminution was unavoidable.
This includes the resident's abilities to bathe, dress, and groom; transfer and ambulate, toilet and eat; and use speech, language or other functional communication systems. A resident who is unable to carry out activities of daily living shall receive the services necessary to maintain good nutrition, grooming, and personal hygiene.
All necessary precautions shall be taken to assure that the residents' environment remains as free of accident hazards as possible. All nursing personnel shall evaluate residents to see that each resident receives adequate supervision and assistance to prevent accidents.
Based on observation, staff interview and record review the facility failed to adequately supervise 1 resident (R4), identified as having a previous choking experience, while eating. R-4 choked on a peanut butter sandwich while unsupervised in the dining room. In addition facility staff failed to identify 1 resident (R11) as pocketing food, leaving R-11 unsupervised in the dining room with food pocketed after a meal.
Findings include:
1.Review of the history dated 3/15/00 reveals that R-4 has a diagnosis of Cerebrovascular Accident, Diabetes and End Stage Renal Disease.
The nurses notes dated 8/19/00 at 6 p.m. state: "Heimlach attempted without any success. Called 911. Started oxygen at 5 per n/c. Laid [R4] in bed, attempted Heimlach without any luck. 911 transported to hospital." Review of the telephone orders reveal that a speech evaluation was ordered on 8/21/00.
The speech evaluation dated 8/22/00 states, "Resident presents with mild/moderate oral preparatory, oral and pharyngeal stage dysphagia complicated by edentulousness and chronically dry mouth. Solid bolus formulation, manipulation and propulsion are impaired. Resident had a recent serious choking incident."
The dysphagia summary dated 8/22/00 to 9/6/00 states, "Skilled observation at meals and continuing patient and staff education on compensatory techniques. Oral motor exercises trained."
The Rehabilitation progress note dated 9/1/00 states, "Resident has been trained on these compensatory strategies: small bite size, avoid hard or tough foods, alternate liquid/solid bolus, eat in supervised area. Nursing staff notified that resident is to eat in supervised area." Review of the progress note revealed that the therapist had discussed a possible diet texture change with R-4. The risk of not complying with the diet changes were explained to R-4 by the therapist. R-4 declined to change her diet. Review of the note reveals that R-4 had "many personal food items in the room" and that R-4 eats the foods "independently" as desired.
The care plan date 9/1/00 states that R-4 had a choking episode while eating
with the following approaches identified:
*"Encourage resident to alternate wet/dry bites of food."
*"Provide prescribed diet."
*"Resident keeps food(fruit, candy, crackers, etc.) in room and eats these
foods as desired."
*"Speech therapy prn."
The nurse's notes dated 9/29/00 state, "1:50 p.m.(approx) Resident was eating a peanut butter and jelly sandwich-resident choked. Brace removed and Heimlach maneuver performed-lips cyanotic. Resident suctioned via mouth et nares with minimal results.
Repositioned on floor from w/c and Heimlach maneuver again. Oxygen started at 12 L/min via face mask-oxygen sat 67-76 percent. Pulse 84 strong, lips remain cyanotic and response to painful stimuli-resuctioned with small amt brownish mucous obtained orally. Resident slowly began with spontaneous respirations and color improved." R-4 was transported and admitted to the hospital.
The nurses notes dated 10/1/00 at 11:30 a.m. revealed that R-4 expired at 10 a.m. on 10/1/00.
During interview on 10/20/00 in clean utility room, E-7 stated, "I was walking with another resident, when she got bushed, we went into the dining room to sit on the couch. [R-4] was in the wheelchair, sitting there with a piece of bread, looked like she had a big mouth full. She had no teeth and she was rolling it around. I teased her about her full mouth and walked to the edge of the dining room and looked down the hall. The other resident said that [R-4] needed help." E-7 confirmed that there were no trays in the dining room or other staff present. E-7 stated, "I only saw the bread in her mouth." When E-7 was asked how big the "wad" of food in R-4's mouth was she replied that it was about 2 inches in diameter. E-7 stated she "hollered for help, took (R-4's) velcro brace off and did the Heimlach maneuver."
E-7 stated, "I thought she was choking." E-7 stated, "I was holding her up and doing the Heimlach, hollering for help at the same time." When asked, E-7 indicated that she did the Heimlach maneuver approximately 6 times before anyone came to her assist. E-7 revealed that she was not aware that R-4 had any problems with choking or swallowing. E-7 revealed that she knew that R-4 kept food in her room and did not comply with programs set up for her.
During interview on 10/19/00 at 1:10 p.m. E-12 stated, "After everyone was done I picked up the trays. (R-4) was done with her peanut butter sandwich. I didn't know that I wasn't supposed to leave her. They sit in here every day after trays are picked up. (R-4) had cookies, apples and oranges in her room--she was in there eating all day. I didn't know she wasn't supposed to eat in her room." E-12 confirmed that she was the aide assigned to the rehab dining room on third floor on 9/29/00.
During interview on 10/19/00 at noon in the medicine room E-11 stated, "(R-4) choked on peanut butter after everybody finished eating." When asked how E-11 knew that R-4 had choked on peanut butter, E-11 replied, "A peanut butter sandwich was right in front of her-one half of it was left."
During interview on 10/19/00 at 2:45 p.m. in the social service office E-2 revealed that R-4 had choked on 9/29/00 and she thought that R-4 had pocketed some food in her mouth. During interview on 10/20/00 at 11 a.m. E-2 revealed that if trays are in the dining room or if a resident pockets food, a staff member should be present. E-2 confirmed that E-12 was the aide assigned to the third floor rehab dining room on 9/29/00.
During interview on 10/19/00 at 2 p.m. in the social service office, E-10 stated that a peanut butter colored fluid was suctioned out of R-4.
2. On 10/19/00 at 1:25 p.m., R-11 was observed sitting in a wheelchair in the third floor rehab dining room. R-11 was observed chewing. No staff were present in the dining room at the time. E-12 was asked to check R-11's mouth for food and confirmed that R-11 had pureed carrots pocketed in the side of her mouth.
Review of the history and physical dated 5/14/00 reveals that R-11 has a diagnosis of cerebrovascular accident with right hemiparesis and motor dysphagia.
The current physician order sheet reveals that on 9/1/00, R-11 was put on a Mechanical Soft diet.
A physician progress note dated 9/15/00 states, "Is more alert today. Was not being helped with feeding, tray was left without opening containers or help. Pocketing food. Pt remains Dysphagia."
Review of a hospital transfer sheet dated 8/6/97 reveals the need to check R-11 for pocketing of food after meals.