BEL-WOOD NURSING HOME
Facility I.D. Number 0004499
Date of Survey: 10/23/01
Sufficient staff in numbers and qualifications shall be on duty all hours of each day to provide services that meet the total needs of the resident.
The advisory physician or medical advisory committee shall develop policies and procedures to be followed during the various medical emergencies that may occur from time to time in long-term care facilities. These medical emergencies include, but are not limited to, such things as: pulmonary emergencies (for example, airway obstruction, foreign body aspiration, and acute respiratory distress, failure, or arrest.)
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 residents 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.
Objective observations of changes in a residents condition, including mental and emotional changes, as a means for analyzing and determining care required and the need for further medical evaluation and treatment shall be made by nursing staff and recorded in the
residents medical record.
All nursing personnel shall evaluate residents to see that each resident receives adequate supervision and assistance to prevent accidents.
Physicians shall write a diet order, in the medical record, for each resident indicating whether the resident is to have a general or a therapeutic diet. The diet shall be served as ordered.
An owner, licensee, administrator, employee or agent of a facility shall not abuse or neglect a resident.
These requirements are not met as evidenced by:
Based on record review, interview, and observation, the facility served and fed one sampled resident (R4) the incorrect consistency diet. Facility staff failed to report to nursing supervisor that incorrect diet was served. The facility failed to recognize and respond to signs and
symptoms of aspiration. R4 was admitted through the emergency room with Aspiration and Hypoxia.
Physician order sheet dated 9/1/01 to 9/30/01 indicated that R4, who was born 1/29/05, has diagnoses including Alzheimer's, Dementia, Non- Insulin Dependent Diabetes Mellitus, and Parkinson Tremor; and verifies that R4's diet order at time of the incident (9/15/01) was for pureed consistency. Dietary note dated 6/13/01 and Minimum Data Set (MDS) dated 7/15/01 indicated that R4 had a problem with chewing and was totally dependent on staff for feeding. According to this same MDS, R4 had "severe cognitive impairment". Physician order sheet dated September 2001 includes an order for oxygen at 2 liters per nasal cannula PRN (as needed) for dyspnea (difficulty breathing).
During interview with E3 (Certified Nurse Aide - CNA) on 10/10/01 at 3:20p.m., E3 stated that Z3 (Agency CNA) came to her at approximately 6p.m. on 9/15/01 with a plate of food and asked, "is this (R4's) food?". E3 said, "No, (R4)'s on a pureed diet". According to E3, she just "glanced at the plate and saw carrots". E3 said that she told Z3 to call the kitchen. E3 stated that she saw Z3 on the phone and then "went about her business".
Interview with Z3 on 10/16/01 at 8:30a.m. verified that Z3 "gave only one little piece of carrot to (R4)" before she "realized that the tray card said puree diet". Z3 verified that there was a hamburger on a bun, carrots, and onion rings on the plate. According to Z3, this was at 5:30- 6:00p.m. Z3 stated during interview that she also fed R4 pudding and milk soaked graham crackers. Z3 indicated "she didn't know (R4)" and "this was the first or second time she had worked on this floor". Z3 said, "(R4) had no coughing or choking, but did sound gurgly". Z3 said that she didn't see R4 again until after Z4 (Agency CNA) had fed R4 the second tray requested from dietary.
According to Z3, R4 was not in her assigned group of residents for the evening of 9/15/01. Z3 verified in this interview that she did not report to the nurse that R4 had received the wrong consistency food on her supper tray.According to interview with E4 (Registered Dietitian/Food Service Supervisor) on 10/10/01 at 9:45a.m., the hot plate portion for general consistency diets on 9/15/01 evening meal included a hamburger on bun, cooked carrots, and onion rings. The facility's investigation report dated 9/25/01 regarding R4 being served and fed the incorrect consistency food verifies that R4 had received 2 incorrect trays for the evening meal on 9/15/01. The first tray contained regular
consistency meat, carrots, and onion rings, while the second tray contained cream of mushroom soup which had not been pureed. During interview with E4, E4 stated she "did not know what happened with the first tray...could have pulled the wrong hot side plate to complete the tray".
Observation of tray service on 10/10/01 and 10/22/01 at 12:30p.m. verify that the system in place in this facility is a divided tray system. Hot food items are plated on one tray and the cold food items are placed on a separate tray. The two trays are placed in a divided cart, directly across from each other. The tray identification card with the resident's name and diet order is only one of the trays. Nursing staff are responsible for pulling the two trays from the cart and taking to the residents in the dining room. Interview with Z4 on 10/22/01 verified tray cards "do not always" go with the food to the table.
During telephone interview with Z4 on 10/22/01 at 4:15p.m., Z4 confirmed that he had fed R4 on 9/15/01. According to Z4 when questioned about feeding R4, Z4 came into the dining area and asked what he could do to help. A staff member, which Z4 could not identify, told him to "finish feeding (R4)". Z4 recalled that R4's tray was in front of her, with cream of mushroom soup and "I'm not sure exactly what it was, but it looked like a pudding". Z4 confirmed that he fed R4 the mushroom soup which had small pieces of mushrooms in it. "She didn't eat much, coughed some, and acted like she did not want anymore". Z4 stated that he considered the coughing "pretty normal...then it's time to quit".
Z4 confirmed during this interview that he did not tell anyone about the coughing R4 did during the meal. Z4 stated the next interaction that he had with R4 was when Z1 (Agency Licensed Nurse) "wanted me to put (R4) in bed because she said (R4)'s lungs didn't sound right". Nursing notes dated 9/15/01 indicate that this was approximately 1 ½ hours after evening meal. Z4 confirmed that a "gurgly sound" could be heard when he stood next to R4. Z4 indicated that "chunks of ground beef-like sloppy joe was present on R4's clothing. Z1 asked Z4 if he had fed R4 any of the meat. Z4 stated that he told Z1 that he had not fed her any meat, but did inform Z1 that he had fed her mushroom soup. According to Z4, this was the first time he had told anyone about feeding R4 the mushroom soup.
This facility is a 300 bed facility with six different wings. Staffing schedules reviewed for the date of the incident and verified with interview with E2 confirm that four CNAs were assigned to R4's wing on 9/15/01. Three of these four CNAs were agency staff. Z4 verfied during
interview on 10/22/01 that at the time of the incident he had not worked much at this facility, mostly "just the past month, and then only 2 times a week on average". Z4 confirmed that he did not always work on the same wing and that "all the wings look alike". During interview
with Z3 on 10/16/01 at 8:30a.m, Z3 stated "this was only the first or second time on the floor".
Z5 when interviewed on 10/16/01 at 9:05a.m. verified that she had "only worked at this facility a couple of times before" and "thought it was the first time" on this wing. Z1 (Nurse Supervisor for R4's wing) is also employed by an agency. During interview on 10/10/01 at 1:30p.m., Z1 stated that she had "not worked this wing much" and "did not know (R4)".
Nursing notes dated 9/15/01 at 7:30p.m. (1 ½ hours after evening meal), and written by Z1, read in part, "resident in W/C (wheelchair) coughing, making 'gurgling noises'. Assessment complete. Lung sounds reveal bilateral rhonchi throughout, tight expiratory wheezes, L (left) greater than R (right), T (temperature) 96.3, P (pulse) 82, R (respirations) 36, BP (blood pressure) 168/98". Nursing note on same day at 7:55p.m. indicate that local emergency personnel "here and transported resident to hospital".
During interview with Z1 at 1:30p.m. on 10/10/01, Z1 stated that she was passing medication and "noticed that (R4) was having problems and was in distress". Z1 indicated that she saw what looked like a small amount of ground meat and some dime size and half dime size carrots in R4's lap. Z1 said that R4 "sounded gurgly" and that she told Z4 to put R4 to bed. According to Z1, R4's "airway was patent but she didn't sound right...lung sounds were decreased throughout". Z1 said that she was unaware that R4 got the wrong tray until after she noticed R4 having problems at time of the medication pass. Z1 said that she "didn't think that (R4) needed suctioning, that (R4) was not cyanotic, and that airway was patent".
Review of facility policy for medical emergencies indicates for respiratory distress: O2 (oxygen) per nasal prongs, suction PRN, and if resident does not respond promptly to above, notify MD (Medical Doctor) for further orders. Review of nursing notes dated 9/15/01 verify that there was no documented oxygen saturation levels, nor is there any evidence of suctioning being done or oxygen applied.
Interview with Z11 and Z12 (Emergency Medical Transport Personnel) at 7a.m. on 10/18/01 indicated that they first saw R4 at 8:22p.m. on 9/15/01 and that R4 was "looking bad...laying in bed at 45 degrees, moaning and head tilted to the side..couldn't track...wasn't in the best position to move air. Her head was turned to right and down. She wasn't cyanotic, but was ashen. Had audible rhonchi that was confirmed with a stethoscope...right lung sounds diminished. Oxygen saturation rate were 68%...could tell airway was compromised...brought up to midline and tilted chin up and put oxygen on. There was no oxygen in the room. There was no suction in the room...". According to Z11 and Z12, R4 was first suctioned in the ambulance. Z11 said they "suctioned several chunks of mushrooms, one piece the size of a dime and a half dozen other pieces. It was not broken down. Other pieces were not as big as the first piece...there was a lot of food down the front of chest...brown". Z12 said "undigested cream of mushroom soup was what was suctioned out...". Z11 and Z12 stated that they used a hard plastic suction tip to suction R4 and that this type of suction tip pulls things out and it pulled chunks of food out". According to Z11 and Z12, R4 was suctioned five times on the way to the hospital, with the "suctioning almost continuous...with a gradual improvement in the oxygen saturation to 94% between oxygen and positioning. Z11 said the "nurse told them that (R4) was fed solid food at 6:30p.m."
Emergency Services Physician Record dated 9/15/01 (page 3 of 4) listed "IMPRESSION: 1. Aspiration with Hypoxia". A second history and physical done 9/20/01 by Z10 (Resident Physician) indicated, "chest x-ray done a day after admission showed CHF (Congestive Heart Failure) and Pulmonary Edema and her ECG (electrocardiogram) showed anteroseptal infarct...It looked like the patient had myocardial infarction secondary to hypoxia causing congestive heart failure...". R4 was discharged on 9/20/01 with discharge diagnosis listed on the discharge summary as "Congestive Heart Failure secondary to Myocardial Infarction...".
R4 returned to the facility on 9/20/01 at 4p.m. with orders for "comfort care only". Facility nursing notes on 9/21/01 at 7:52p.m. indicated R4 "had no blood pressure or pulse".
Death certificate signed by Z6 (Facility Attending Physician) listed the "immediate cause" (final disease or conditions resulting in death) as "Aspiration pneumonia...due to or as a consequence of...Dementia...Parkinson's disease". During interview with Z6 on 10/11/01 at 1:10p.m., Z6 indicated R4 was "demented and they can easily aspirate".
Z7 (Hospital Physician), who saw R4 during hospital stay, was interviewed by phone on 10/11/01 at 1:25p.m. Z7 said "choking and aspiration could have been the main trigger, initial event. All problems could have been precipitated by aspiration...couldn't say for sure. If hypoxic, not enough oxygen to the heart, could cause a strain on the heart".