| 74 |
SERENITY REHABILITATION AND HEALTH CENTER LLC |
95015 |
1380 SOUTHERN AVE SE |
WASHINGTON |
DC |
20032 |
2018-07-20 |
726 |
G |
0 |
1 |
L7I811 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review, and staff interview, the facility failed to ensure the nursing staff provided necessary care and treatment with an acute change in condition as evidenced by the failure to monitor, assess, evaluate and implement interventions, in accordance with professional standards of care, for one (1) resident with a history of dysphagia that experienced a choking episode. (Resident #158) Findings included . Resident #158 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Speech Evaluation and Plan of Treatment dated (MONTH) 13, (YEAR) at 4:38 PM showed reason for referral: Resident referred to SLP (Speech Language Pathology) evaluation due to difficulty speaking and coughing while eating. The speech evaluation included recommendations for mechanical soft textures, mechanical soft/ground textured solids; nectar thick liquids with close supervision for oral intake. Swallowing strategies included seated in chair or edge of bed for all PO (oral) intake. Liquids consumed with head posture chin down. Review of medical record on [DATE], at 10:00 AM showed an Admission Minimum Data Set ((MDS) dated [DATE]. Review of the MDS Section C showed the Brief Interview for Mental Status score was coded as 13, which indicates the resident is cognitively intact. Section G0110 Eating resident was coded as 1 which indicates set up help only. Section K0510 (Nutritional Approaches) the resident is coded as requiring a mechanically altered diet (requires change in texture of food or liquids, e.g. pureed food, thickened liquids). Speech Therapy Treatment Encounter note dated [DATE] at 5:42 PM, showed regular nectar thin liquids presented mild cues for head posture chin down during liquid intake. The Nurse's Note dated (MONTH) 17, (YEAR), at 11:15 PM showed that Resident #158 was in the Day Room with other residents eating a steak and cheese sub from a local carry out when a staff member yelled for help at about 9:40 PM. Upon entering the Day Room, the nurse observed the resident sitting in his wheelchair coughing/choking and his eyes rolling backward. The nurse called for help and performed five (5) back blows on each shoulder blades. Resident #158 coughing increased. In addition, the Nurse's Note showed abdominal thrusts were performed three (3) times but the resident condition is not improved. He went into code and CPR (Cardiopulmonary Resuscitation) was initiated and 911 was called, resident was intubated and then transferred to (Hospital Name). Further review of the medical record showed an eInteract Change of Condition Evaluation Form dated (MONTH) 17, (YEAR), at 9:59 PM. The form showed Resident #158's [DIAGNOSES REDACTED]. The most recent vital signs recorded as [DATE] at 9:40 AM- ,[DATE], pulse- 78 beats per minutes, respirations- 20 breaths per minutes, and the most recent temperature recorded as 98.4 degree Fahrenheit orally at 2:28 PM on (MONTH) 17, (YEAR). The most recent oxygen saturation recorded as 98% (percent) on (MONTH) 16, (YEAR) at 11:03 PM. The physical assessment showed Resident #158 had no observed neurological changes but was also unresponsive, and choking. Under section summarize your observations and evaluation: Resident was eating outside food steak and cheese sandwich when he began choking. The interventions documented were 911 was called and CPR continued, resident was transported via 911. During a face-to-face interview on [DATE] with Employee #26 at 4:21 PM regarding the resident change in condition, I completed the Nursing Home to Hospital Transfer Form on [DATE] and I assisted with CPR (cardiopulmonary resuscitation) for Resident# 158. When I came in the dayroom I saw the resident trying to stick his hand down his throat , we (staff) were trying to get him to stand and he could not stand he was conscious and I was telling him to cough and Employee# 25 did the back slaps over his shoulder blades, he had cup of water he was trying to drink it and it was coming out of his mouth, then he could not breathe he was shaking and he became stiff and he was not breathing and we started CPR we called a code and 911, the supervisor (Employee# 27) came to the floor and took over CPR. During a telephone interview on [DATE] at 5:35 PM, Employee# 24, stated I was in the dayroom but I was not assigned to the resident and three residents came in with food from the outside; Resident#158 and two other residents. I was not too far away and he asked for sips of water, thickened water. While they were eating I gave him the thickened water and then I asked him if he was choking. He said yes, he only took a few bites before he started choking. It was not a long time at all, if ten minutes, before he started choking. He had a lot of sandwich left. I saw staff in the hall way and called for help they came in and started working on him. During a face-to-face interview with Employee #27 on [DATE] at 5:00 PM, they called a medical emergency and I came from the first floor and I met the Resident# 158 holding his throat he said that he just choked he stood up and we supported him I did the [MEDICATION NAME] Maneuver and then we placed him on the floor and I took over CPR, oxygen and suction with a Yankeur (oral suction tool), by now 911 had arrived and his SP02 (oxygen level) was 62% they (911) took over chest compressions with an automatic chest compression system they (staff) pulled out a big piece of meat, he was alive when he left the floor he was to go (hospital name) but he went to (hospital name). Review of the facility policy titled Serenity Rapid Response Team dated (MONTH) 27, (YEAR), showed that staff are to respond to all emergencies to include a licensed nurse from each unit and the Director of Nursing/Nursing Supervisor, and Nurse Practitioner , if available. The Director of Nursing/Nursing Supervisor is responsible for bringing the AED (Automated External Defibrillator). Review of the American Heart Association Guidelines (YEAR)/ CPR & ECC for Choking Relief in a Responsive Adult includes positioning self behind the choking victim and wrap arms around the victim's midsection and search for their bellybutton. Make a fist with one hand and grasp it with the other hand and thrust both hands inward and upward, until the blockage comes out. If the patient loses consciousness and the blockage remains, lower the patient to the floor. Open the mouth with the head tilt/ chin lift and look inside for the item and begin chest compressions. Reassess for expelled object and pulse until paramedics arrive. The facility failed to show all interventions implemented to include complete vital signs, administration of oxygen, suctioning, the performance of a comprehensive assessment, cardiovascular assessment, respiratory assessment, and neurological assessment at and during the change of condition. In addition, review of the interventions provided during the choking episode showed the interventions taken were inconsistent with acceptable professional standards for care of choking resident. During a face-to face-interview on (MONTH) 20, (YEAR), Employee #1 and 2 acknowledged the findings. |
2020-09-01 |