Facility I.D. Number 0007880
Date of Survey: 03/22/02
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.
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.
The DON shall oversee the nursing services of the facility including:
Overseeing the comprehensive assessment of the residents needs, which include medically defined conditions and medical functional status, sensory and physical impairments, nutritional status and requirements, psychosocial status, discharge potential, dental condition, activities potential, rehabilitation potential, cognitive status, and drug therapy.
AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT NEGLECT A RESIDENT. (Sections 2-107 of the Act)
These regulations are not met as evidenced by:
Based on interview and record review the facility failed to reassess, care plan, implement interventions, and provide dining supervision for two residents (R2 and R4) to prevent choking incidents. Specifically for R2, with a previous incident of choking, and R4, who had been assessed with dysphagia. R2 and R4 choked on food items on 3/13/02 which led to the death of both residents.
1. Review of R2's clinical record reflects that R2 is a 96 year old resident admitted to the facility on 11/27/98 with diagnoses that include hairy cell leukemia, dementia, and gastroesophageal reflux disease. According to R2's most recent assessment dated 2/13/02, R2 needs extensive assist to transfer and for all activities of daily living. R2 is not ambulatory and requires extensive assist for eating. The assessment reflects that R2 is moderately impaired for cognitive/decision making abilities. The assessment documents no difficulties with chewing or swallowing. The record reflects that R2's current diet order to be "regular diet with ground meat as needed".
Review of an incident report dated 3/14/02, transmitted via fax at 2:30 p.m. on the same date from the facility to the State Survey Agency Regional Office, R2 is described as being "found slumped over in w/c (wheelchair), assessed to be unresponsive/ no HR (heart rate)/ no resp (respirations)/ no B/P; (blood pressure); client was a DNR (do not resuscitate); assessment /procedures discontinued due to DNR order."
Review of nurse's notes dated 3/13/02 at 7:30 a.m. confirm that R2 had been seated at the dining room table with a bowl of prunes in front of her, prune juice on her lips, with staff checking for the presence of prunes in her mouth. The nurse's aide E6 then moved the prunes away from the resident. A nurse's note with the same date at 7:32 a.m. reflects that E6 then noticed that R2 was slumped over as E6 approached and noticed that R2 was pale, unresponsive, and lips cyanotic. E6 then summoned the nurse, E8, who attempted a finger sweep of the oral cavity in the dining room, removed the resident to the lobby where another finger sweep was attempted, then took the resident to her bedroom (which was determined to be 42 paces from the interior of the dining room) where further attempts were made to open R2's airway. The note reflects that 2 Heimlich thrusts were administered prior to placing the unresponsive resident into her bed. An additional finger sweep is documented as being performed with a chewed prune being retrieved. The note documents that the resident remained unresponsive with a faint carotid pulse present and a gurgling noise being made by R2. The note states that oxygen was administered per nasal cannula at 2 liters per minute and suctioning was initiated with retrieval of a small piece of prune and brown liquid. The note reflects that R2 continued to be suctioned for approximately 5 minutes at intervals with no blood pressure present, no respirations, and a faint carotid pulse present. The note reflects that staff were unable to revive R2, no carotid pulse present. All procedures were then stopped by staff. A note dated 3/13/02 at 7:38 a.m. reflects that R2 expired.
Review of a "Report Of Death" for R2, dated 3/13/02, issued by the county coroner confirmed that the "Final Cause (s) of death" for R2 to be "A. Foreign Body Airway Obstruction and B. Choking on A Prune".
Nurses notes in R2's record dated 2/18/02 document a previous incident of R2 choking while eating prunes. The entry reads, "2/18/02 (0730) Res (resident) in w/c (wheelchair) in dining room for breakfast when dietary aid noted resident was cyanotic et (and) unresponsive. Res (resident) taken to her room et (and) placed in bed (with) HOB (head of bed) (elevated), res (resident) suctioned et (and) piece of a prune was retrieved per suctioning. Res (resident) began coughing a little color returned to face, res (resident) became responsive...."
Interview with E2, the DON (director of nursing) on 3/15/02 at approximately 4:00 p.m. confirms the facility decided R2 was not to have whole prunes anymore. E2, the DON stated, "Yes we were aware that she choked on the prune on 2/18/02. We made a nursing order for her to have prune juice instead of whole prunes. No, it is not on the care plan and we did not do a formal assessment (related to the choking episode)."
Interview with E6, CNA (certified nursing assistant) on 3/15/02 at approximately 3:00 p.m. reflect that some facility staff were aware of a problem with R2 eating prunes and failed to supervise her. E6 states, "I was here Wednesday morning 3/13/02, I was passing trays in the dining room and bringing residents in. I brought in a resident (R3) who sits at (R2's) table. I noticed (R2) was eating prunes, I took the prunes away from her and looked into her mouth and observed that she (R2) had been eating a prune. She was alert and smiling. I walked away and started passing trays. I served 2 or 3 residents, I then noticed (R2) did not look right. I went over to her and noticed the prunes were back in front of her. There was no one, no CNA, sitting at that table. I then yelled for the nurse. (R2's) color was bad and her head was slumped forward. We started to push her backwards through the doorway and to her room. (E8) did the Heimlich then we put her in bed. We pried her mouth open and I could feel the prunes, I dug them out. (E8) lifted her head up and I think she (R2) took a breath. We put O2 (oxygen) on her and (E8) was suctioning. We had tried to open her mouth in the dining room."
Interview continued with E6, CNA, on 3/19/02 at approximately 2:10 p.m., which confirmed that when E6 moved the prunes she did not move the prunes out of R2's reach. E6 stated "When I moved the prunes I put them to the front and (to) the right of (R3). (R3) sat next to (R2) with enough room in between for a CNA to sit. They (dietary staff), would have set the prunes where (R3) sits, when they first brought them out. I was aware of the choking incident a month ago (2/18/02) I knew she was not to have prunes, but we were not told officially."
Interview with E9 (dietary manager) on 3/15/02 at 3 p.m., confirmed that the facility dietary staff passed bowls of fruit to the resident dining tables before the regular trays were passed. E9 states, "Yes we always passed the fruits before the regular trays...."
Interview with E5, CNA, confirmed it is facility practice for dietary staff to pass fruit in the mornings before residents are supervised. E5 confirmed that not all of the CNA's were in the dining room on the morning of 3/13/02 when food was available to residents. E5 stated,"I was in the dining room that morning (3/13/02) between 7:30 and 8:00 a.m.. All the CNA's were not in the dining room, some were still bringing residents to the dining room. There was not a CNA at (R2's) table and the fruits (prunes and grapefruit sections) were on the table. (R2) was capable of getting and reaching for a prune for herself. I was not aware of the choking incident of 2/18/02 and I did not know (R2) was not supposed to eat whole prunes."
Review of R2's most recent care plan dated 2/21/2002 confirms that R2 is not to be left unsupervised at meal time. The Care plan states, "Provide setup assist and supervision with (R2's) eating at all meals".
2. Review of an incident report dated 3/13/02, received via fax on 3/14/02 at 2:30 p.m. from the facility reflects that at 12:30 p.m. R4 was "found slumped over in w/c at DR (dining room) table, color pale, no HR or respirations; airway checked with resistance; Heimlich maneuver completed with airway regained, mouth to mouth continued; client had no return of HR (heart rate), B/P, or respirations; procedure stopped due to DNR order."
Review of a "Report Of Death" for R4, dated 3/13/02, issued by the County Coroner confirmed that the "Final Cause (s) of death" for R4 to be "A. Foreign Body Airway Obstruction and B. Choking on piece of sausage".
Review of R4's clinical record reflects that R4 is an 84 year old female that was admitted to the facility on 8/3/00 with diagnoses including hypokalemia, anemia, and s/p left hip fracture. According to R4's most recent resident assessment instrument dated 12/19/01; R4 needs extensive assist to transfer and is incontinent of bowel and bladder. R4 is not ambulatory and is assessed as independent in eating.
Review of a report contained in R4's record titled "Plan Of Progress For Patient Rehabilitation" and dated 2/05/01, which is signed by a speech language pathologist and R4's physician, confirms that R4 was diagnosed with dysphagia (difficulty swallowing). The report states under General Assessment, "....Eval (evaluation) was conducted during noon meal, PT (patient) given trials of puree;mech (mechanical) soft, & regular. She demonstrates (decreased) rotary chew & in fact has a weak munching chew. It appears that food is poorly masticated (chewed). This is confirmed by large emeses (with) large poorly chewed chunks of food. Oral function appears WNL (within normal limits) other than (decreased) strength of chew. Swallow was timely and laryngeal elevation was WNL. Diet (change) to regular consistency is appropriate if food is cut into small pieces and patient is in an area where she can be supervised by staff in case of choking...."
Interview with E4, CNA, on 3/19/02 at approximately 12:40 p.m. confirmed that R4 was not being supervised during the noon meal on 3/13/02. E4 stated, "I was here on 3/13/02 at lunch time about 12:30 p.m. I was passing hall trays that day and I was dropping off a tray I had picked up at the back of the kitchen. A dietary aide (kitchen helper and non direct care staff) said '(E4) come here (R4) is unresponsive.' I walked over to (R4) and she was slumped down, I knew something was wrong immediately...... I ran and got (E10), nobody, no staff, was in the back dining room. (E10) took one look and took her from the back part of the dining room to the main dining room... When I came back they were doing the Heimlich, they got the piece of meat out....."
Interview with E10, LPN (licensed practical nurse) on 3/15/02 at 2 p.m. confirmed that R4's food was not cut up into small bites as ordered by the physician. Interview with E10 also reflects that some facility staff were unaware of R4's dysphagia and the physician's order requiring R4's food be cut into small bites; the interview reflected that staff were unaware for R4's need for supervision when eating. E10 stated, "I was working 6a.m.-2:30p.m. on 3/13/02. I was called into the dining room by (E4).... I found (R4) was pale, her extremities were flaccid and she was non-responsive....I started to wheel her out of the area, I wanted to get her to an open area.... We put her on the floor, we assessed for breathing, tried to get vital signs. They (one of the nurses) did a finger sweep and got a piece of polish sausage, an intact bite that was about the size of a half dollar and about ½" thick.... My knowledge is that she did not require supervision when she was eating. I don't know of any recommendations for the resident's (R4) food preparation."
Interview with E2, the DON (director of nursing) on 3/15/02 at 10 a.m. confirmed that the chewing/swallow problem of R4 was not assessed by nursing and the physician's order did not appear in R4's care plan. R2 stated,"The care plan does not reflect the recommendations by the speech pathologist/physician that the resident have her food cut into small pieces and that she be supervised when eating, it should have. The resident (R4) was in the independent part of the dining room. There were no staff that supervised that part of the dining room directly for the entire meal."