Washington Heights Nursing Home Facility I.D. Number 0042044 Date of Survey: 01/10/02 Incident Report Investigation of December 25, 2001 “A" VIOLATION(S): 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 andpersonal care shall be provided to each resident to meet the total nursing and personal care needs of the resident. A diet order for each resident shall be sent in writing to the food service department. The diet order shall include at a minimum the following information: name of resident, room and bed number, type of diet, date diet order is sent to dietary, name of physician ordering the diet, and the signature of the person transmitting the order to the food service department. Foods shall be attractively served at the proper temperatures and in a form to meet individual needs. AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT. (Section 2-107 of the Act) This REQUIREMENT is not met as evidenced by: Based on staff interviews, other interviews, and review of the clinical record, incident report and facility’s menu, the facility failed to provide food prepared in a form designed to meet the resident’s assessed needs (mechanical soft diet), for one of one residents in the sample. As evidenced by the following: A certified nurses assistant (CNA) served a resident (R3) a polish sausage that she cut up which resulted in the resident choking and going to the hospital. At the hospital, the resident was diagnosed with “Acute Food Aspiration, Cardiac and Pulmonary Arrest”, the resident expired at the hospital. Findings include: On 01/07/02, R3's clinical record was reviewed. R3's clinical record reflects documentation that on 12/25/01 at 6:45pm, R3 was sent to the hospital after the facility staff called 911 to have the resident transferred to the hospital. On 01/08/02 at 1:30pm, Z2, the manager of the hospital Emergency Room (ER), was interviewed by phone. Z2 stated that R3's medical records reflected that R3 came in to the hospital on 12/25/01 with no vital signs. Emergency Room Notes from Little Company of Mary dated 12/25/01 reflected that the paramedics pulled a medium sized piece of meat from R3's throat and gave it to the ER staff. Z2 stated R3 had a diagnoses of “Acute Food Aspiration, Cardiac and Pulmonary Arrest”, and R3 was pronounced dead at 7:19 pm. Z4 was interviewed by phone on 01/10/02 at 2:35 pm. Z4 stated when he arrived at the facility, Z4 and his partner found R3 sitting up in a wheel chair with a cushion in front of R3. Z4 reported R3 was conscious, but in distress. Z4 said staff told him R3 had choked on a piece of meat, but R3 was fine, and needed to go to the hospital to be evaluated. Z4 stated once R3 was in the ambulance, he started to deteriorate. Z4 said they checked R3's airway again, and found it obstructed. Then Z4 stated a blade was used to remove a piece of hot dog (approximately two inches) from R3. However, Z4 stated medical interventions did not prevent R3 from going in to Cardiac and Pulmonary Arrest, and R3 presented in ER with no pulse, blood pressure, or respirations. R3 was a 63 y/o male admitted to the nursing home on 5/7/98 with multiple diagnoses, including, Anemia, Dysarthria, Dysphagia Major Depression, Cerebral Vascular Accident, Hypertension and Deep Vein Thrombosis. On 1/8/02 at 11:00am, E6 was interviewed per phone. E6 reported that she worked on 12/25/01 and she (E6) was the C.N.A. who served R3 his dinner tray. E6 stated that R3's tray was served to R3, while R3 was in the dining room waiting to eat his dinner. E6 stated “R3 was fine in the dining room”. “When R3 got to his room, R3's roommate put on the call light”. E6 reported R3 was found with his head held backward. E6 said “we could see he was choking”. We started Cardio Pulmonary Resuscitation (C.P.R.), we did the Heimlich Maneuver. Surveyor asked E6, “what did R3 eat?’ E6 replied “R3 had a Polish Sausage. It was a Polish Sausage cut up. I cut it up. It came up whole. I cut it up into small parts. I know they had Polish Sausage, I don’t know what diet he was on. I didn’t know he was on a Mechanical Soft diet, but he had a Polish Sausage, and I cut it up. I don’t have him all the time since I’ve been working there, (working at the facility seven or eight months), I watched him eat the whole meal, he was fine. I watched him wheel himself into his room.” When the Heimlich Maneuver was performed, E6 said she observed little bits and pieces of the Polish Sausage come up. E6 also reported that the incident happened 20 minutes after R3 ate his meal. At 4:35pm on 1/07/02, E3 was interviewed in the conference room which is located on the first floor of the facility. E3 said she was one of the nurses working on the 3-11 shift on 12/25/01. E3 stated “I was on the phone. I heard a C.N.A. say something was wrong with R3. They said R3 looked like he was coughing. We got a lot of mucous out, we took turns doing the Heimlich Maneuver on R3. The other nurse said it looked like we need to call 911". They came within less than 10 minutes. Surveyor asked E3 if R3 was on any monitoring precautions. E3 replied “R3 is on swallowing precautions and needs to be monitored while eating. I was in the dining room before it happened. R3 needs supervision during meals. R3 is on a Mechanical Soft diet”. E3 reported hot dogs were served that day, and the incident happened shortly after dinner. E4 was interviewed on 1/7/02 at 4:40pm in the conference room on the first floor of the facility. E4 said she usually works on the 3-11 shift and was working the evening of 12/25/01. E4 stated I was R3's nurse a lot. R3 was paralyzed on the left side. He didn’t talk. He responded by nodding his head. When R3 wants something, he’ll point. R3 was quiet, nice and not confused. R3 had no problems with coughing. R3 was all right. R3 ate dinner in the dining room, up in his wheelchair. I was passing medications. R3 took his medications before the meal. At 6:45pm , a C.N.A. called me to his room, after the meal. R3 always wheeled himself in his wheelchair to the room. E4 reported when she got to R3's room, R3 was unresponsive. E4 stated “I looked in his mouth. R3 had undigested food in his mouth. I did the Heimlich Maneuver. E4 said R3 became alert and R3 coughed up food, secretions and everything. E4 stated “R3's body was warm. I called the nurse to call 911. When paramedics came, R3 was alert”. Surveyor asked E4 what type of diet was ordered for R3, and was R3 on any precautions? E4 replied “R3 was on a mechanical soft diet. E4 stated “I do not know”. I was not aware of aspiration precautions for R3. Review of R3's clinical record found a physician’s order that R3 was to have a mechanical soft diet. Review of R3's most recent Minimum Data Set (MDS) assessed R3 as having chewing and swallowing problems, and requiring a mechancial soft diet. R3's swallowing evaluation dated 6/21/00 reflects the following for Discharge Recommendations: “remain with mechanical soft diet, continue with liquids, continue to monitor for any signs/symptoms of aspiration.” Review of the facility’s menu found the following food items being served on 12/25/01, “Polish Sausage, Hot Dog Bun, Oven Browned Potatoes, Sauerkraut and Ambrosia.” Review of R3's care plan reflects that “Mechanically Altered Diet Due to Difficulty in chewing” was identified as a problem. The following nursing intervention was to be implemented by staff: (3) Prepare and serve meals as ordered.” The facility dietary manual for mechanical soft diet indicates that meats should be “ground or finely chopped”. During a phone interview with E1, E1 stated that dietary aides are responsible for chopping up the meat for the mechanical soft diets. |