Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for diet consistency were followed for one of 12 residents reviewed (Resident 1), creating a situation in which the resident's safety was in Immediate Jeopardy related to being given regular consistency food, aspirating, and dying.
The facility's policy regarding therapeutic diets, dated December 1, 2019, indicated that a therapeutic diet included an altered consistency diet, that it must be prescribed by the attending physician, and that a resident's snacks should be compatible with the therapeutic diet.
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 25, 2019, indicated that the resident was cognitively impaired and required supervision and set-up help for eating. Physician's orders, dated December 5, 2019, included an order for the resident to receive a controlled carbohydrate diet, pureed texture (foods that have been mechanically altered and do not have to be chewed), with thin (regular) consistency liquids, and pleasure foods with supervision recommended.
A speech therapy discharge summary for Resident 1, dated December 18, 2019, indicated that the resident had been on a mechanical soft diet and she was trialed (downgraded) to a pureed diet to ensure her safety and tolerance of her diet. With the mechanical diet she was observed to have impulsive rate, unsafe amounts of large bites, and had reduced chewing; therefore, she was changed to a pureed diet with pleasure foods. The recommendations were that during her oral intake to alternate liquids and solids, rate modification, bolus size modifications and general swallowing techniques.
A nursing note for Resident 1, dated December 21, 2019, revealed that a nurse aide noticed a change in the resident's condition. The resident was observed to have a skin color change from yellow to ashen (grey tone to the skin). The nurse aide indicated that the resident was eating peanut butter crackers; therefore, the nurse began the Heimlich maneuver with nothing expectorated and cardiopulmonary resuscitation (CPR) was initiated. A nursing note dated December 21, 2019, at 6:44 a.m. revealed that the resident was transferred to the hospital for evaluation.
Interview with Licensed Practical Nurse 1 on January 22, 2020, at 7:50 p.m. revealed that on December 21, 2019, she gave regular crackers with peanut butter to Resident 1 because she heard that others gave peanut butter crackers to the resident for a snack because she liked them. She stated that she was unaware of the resident's actual diet order until after the incident.
The facility's undated investigation statement for Licensed Practical Nurse 4, and an interview with Licensed Practical Nurse 4 on January 22, 2020, at 7:11 p.m., revealed that during CPR performed on Resident 1 on December 21, 2019, she documented what was occurring, and the documentation indicated that emergency medical services (EMS) noted to her that "the airway establishment was complicated by what appeared to be peanut butter."
Interview with Nurse Aide 3 on January 23, 2020, at 3:18 p.m. revealed that he was assigned to do one-to-one observation of Resident 1 on December 21, 2019, and the resident wanted a snack. The nurse gave her a packet of peanut butter crackers and she fed herself the whole pack. The nurse aide indicated that he was not aware of the resident's diet order. After eating the crackers, the resident became unresponsive.
Resident 1's death certificate, dated December 21, 2019, indicated that her primary cause of death was aspiration (inhaling a foreign material or food into the lungs) and the interval from onset to death was "minutes."
Interview with the Director of Nursing on January 22, 2020, at 5:59 p.m. revealed that the facility did not have any guidelines for staff regarding what "pleasure foods" were, and that nursing staff were to check residents' diet orders when giving snacks.
On January 22, 2020, at 11:19 p.m. the Nursing Home Administrator was informed that the health and safety of residents were in Immediate Jeopardy due to registered nurses, licensed practical nurses and nurse aides not knowing how to locate a resident's ordered diet or what consistencies the residents could be served.
The facility submitted and implemented an immediate plan to ensure resident safety by completing an audit for all residents to ensure that their ordered diet, kardex and care plans matched; providing education to nursing staff regarding where to find a resident's diet consistency; how to access the residents' kardex (which contains diet orders); what snacks are safe for residents based on their specific diets; and posting signs at each nursing station regarding what snacks are safe for each diet consistency.
The Immediate Jeopardy was lifted on January 23, 2020, at 7:30 p.m. when it was confirmed that an audit was completed for all residents; that over 90 percent of the nursing staff received the education, with the remaining staff scheduled to receive the education prior to the start of their next shift; and that the facility posted signs at each nursing station regarding what snacks were safe for each diet consistency.
28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 12/17/19, 8/29/19, 5/2/19, 6/29/18.
28 Pa. Code 201.18(b)(1) Management.
Previously cited 12/17/19, 5/2/19.
28 Pa. Code 201.18(e)(1) Management.
Previously cited 12/17/19, 5/2/19, 6/29/18.
28 Pa. Code 211.12(d)(3) Nursing services.
Previously cited 12/17/19, 8/29/19, 8/13/19, 5/2/19, 6/29/18.
28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 12/17/19, 8/29/19, 8/13/19, 5/2/19, 10/22/18, 9/18/18, 6/29/18.
| ||Plan of Correction - To be completed: 02/20/2020|
Resident #1 expired on December 21, 2019
Licensed Practical Nurse was educated on how to access kardex and care plan to determine residents diet on December 23, 2019.
Post the event on December 21, 2019 the facility initiated a plan on December 23, 2019 to address residents care plan and kardex indication of resident's diets and texture. Audit of current resident was completed to validate that the current physician orders matched the care plan and kardex and where needed updates were made on the care plan/kardex. This was completed by the Director of Nursing and Assistant Director OF Nursing. In conjunction with therapy and. Dietary.
Residents on a "Special Liberalized diet" such as comfort foods or pleasure foods were monitored to ensure that they were still appropriate and if not were discontinued.
Education was initiated for licensed nurses and nursing assistants on how to access point click care (facility electronic medical record) to identify resident's diet/texture of resident's diet on December 23, 2019. This education included diet types, what a staff member can and cannot give to a resident on a modified diet and how to locate the information.
A copy of Approved snack list based on diet and texture was developed and placed on the nursing unit for reference on January 17, 2020.
Random audits were completed to ensure diet orders match the care plan and kardex.
On January 22, 2020 when the jeopardy was called the facility submitted a plan to include the steps that were completed in December as well as speech therapy and dietary developed safe food choices that are within the resident's diet restrictions. Listing of "Always available" food based on diet restrictions education was initiated on January 23. 2020 and posted on each unit on January 23, 2020. The snack and always available choices will be maintained and monitored by the dietician.
An ongoing audit speech therapy recommendations will be reviewed and provided to nursing administration to obtain the physician order and ensure that it is placed in the medical record (care plan/kardex). Nursing is responsible for review of recommendation with the physician for approval. Therapy representative will attend morning clinical meeting for review of resident updates and/or changes needing additional services.
At the time of the exit on January 23, 2020 90% of staff have been educated on how to access care plan/kardex and the "Always Available" food list.
Directed in-service will be conducted by a Department of Health vendor on February 12, 2020 for F tag F805 42 CFR 483.60(d)(3) Food in Form to Meet Individual Needs - All staff involved in serving residents food and drink, and in assisting residents to eat and drink, must receive training related to ensuring that appropriate and correct food and drink consistencies are served and/or provided. The training must include information regarding the facility's systems for ordering, care planning, assessing and monitoring correct diet consistencies, and when and how to access the resident' s diet order
Audits of new speech therapy recommendations and diet orders present on care plan and kardex will be completed by the Director of Nursing/designee. This audit will be performed 5 times per week for 1 month then 3 times week for 1 month and weekly for 1 month.
Results of audits will be reviewed by the Director of Nursing with the Quality Assurance and Performance Improvement committee for any systematic changes.