| 10413 |
CEDAR SPRINGS HEALTH AND REHAB |
115381 |
148 CASON ROAD |
CEDARTOWN |
GA |
30125 |
2009-06-03 |
365 |
K |
1 |
0 |
80UN11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, hospital document review, and staff interview, the facility failed to provide food prepared in a form to meet the individual needs of one (1) resident (#1), of a total of five (5) residents on the survey sample who had been assessed to need, and ordered to receive, pureed food, on the total survey sample of twelve (12) residents. A total of fifteen (15) residents (including Residents #1, #3, #8, #9 and #10 on the survey sample) required pureed diets. This resulted in serious harm to Resident #1, who was subsequently diagnosed with [REDACTED]. It was therefore determined that an immediate and serious threat to resident health and safety existed from May 17, 2009 through June 3, 2009, at which time the facility took action to abate the immediate jeopardy. Findings include: Record review for Resident #1 revealed a speech therapy Progress Note of 06/06/2008 which indicated that the resident had been receiving skilled speech therapy and could safely swallow a pureed diet. A 05/09/2008 Telephone Order specified that the resident receive a thin puree diet. Further record review revealed a May 2009 physician's orders [REDACTED]. A Nurse's Note of 05/17/2009 at 9:20 a.m. documented that a certified nursing assistant (CNA) had summoned Nurse "AA" to the South Wing where this nurse observed Resident #1 lying on the floor, and observed another nurse administering the [MEDICATION NAME] Maneuver and a CNA doing mouth sweeps. Nurse "AA" documented that she noted the resident's breathing to be shallow and went to get a Rescue Bag. Nurse "AA" documented that upon returning, she took over administering the [MEDICATION NAME] Maneuver and the other nurse took over doing mouth sweeps. This Note documented that Emergency Medical Technicians then arrived and took over the resident's care, and that the physician was notified. A Nurse's Note of 05/17/2009 at 12:00 p.m. documented that the resident had been transferred to the hospital. A 05/17/2009 Physician Clinical Report from the hospital emergency department documented that the chief complaint was that the resident had been eating a peanut butter sandwich and had been found unresponsive. The hospital Chest X-ray report included in the Findings Section that aspiration was not excluded. During an interview conducted on 06/01/2009 at 12:30 p.m., the Administrator acknowledged that on the date of the incident referenced above, CNA "BB" had given Resident #1, who was to receive a pureed diet, a peanut butter sandwich and the resident had choked. During an interview conducted on 06/03/2009 at 2:45 p.m., CNA "BB" stated that at the time of the incident referenced above, Resident #1, who was in the hallway, told the CNA that he/she was hungry. The CNA stated that she then proceeded to the dietary department, asked Dietary Staff "CC" to provide a sandwich for Resident #1, and was told to get a sandwich from the cooler. The CNA stated that she obtained an unlabeled peanut butter sandwich, returned to the unit, and gave the sandwich to the resident. The CNA stated that she then went to the Break Room, and then heard someone saying that "she's choking." The CNA stated that she called for the nurse and went to call Emergency Medical Services (EMS) 911. The CNA further stated that as nursing staff were doing the [MEDICATION NAME] Maneuver on Resident #1, she observed part of the sandwich coming out of the resident's mouth. A Nurse's Note of 05/17/2009 at 12:30 p.m. documented that the resident had returned to the facility from the hospital. A Nurse's Note of 05/18/2009 at 3:30 a.m. documented that the resident had become lethargic, had cold and clammy skin, pale and ashy color, an oxygen saturation level of only 68, and shallow respirations. A Nurse's Note of 05/18/2009 at 3:45 a.m. documented that EMS 911 had been called to transport the resident to a second hospital, and a Nurse's Note of 3.55 a.m. documented that EMS staff had arrived to transport the resident to the second hospital. The 05/18/2009 History and Physical from the second hospital documented the resident's chief complaint as unresponsiveness and decreased oxygenation at the nursing facility. This History and Physical documented that the resident was admitted to the hospital for the possibility of aspiration pneumonia. The hospital Discharge Summary of 05/22/2009 documented a Discharge [DIAGNOSES REDACTED]. During the 06/01/2009, 12:30 p.m. interview referenced above, the Administrator acknowledged that Resident #1 had a physician's orders [REDACTED]. However, the Administrator acknowledged that on 05/17/2009, the CNA had given the resident an un-pureed peanut butter sandwich. The Administrator further acknowledged that prior to this choking incident involving Resident #1, the facility did not have a functional system which ensured that staff were always aware of residents who had orders for, and were to receive, pureed diets. Administrative staff provided a list of residents which documented that as of 05/18/2009, a total of fifteen (15) residents required pureed diets. Based on the above, it was determined that an immediate and serious threat to resident health and safety existed from May 17, 2009 through June 3, 2009, at which time the facility had completed the following actions to abate the jeopardy situation: 1. Only nurses will obtain and give out snacks to ensure that residents receive food of the proper consistency. All snacks will be locked up and out of residents' reach to ensure that only charge nurses obtain and give out snacks. 2. A list was created listing all residents with orders for pureed diets and was posted in the front of the Activities of Daily Living books, the Medication Administration Records, and the Dietary Intake Book. Copies were provided to the Dietary Department and the Activities Department. This list is to be updated when changes in resident diet orders occur, and will be monitored by charge nurses. 3. A list of all resident diets was placed in front of the Activities of Daily Living books, Medication Administration Records, and Dietary Intake Book. This list is to be updated by the Dietary Manager when diet orders are changed, and the Assistant Director of Nursing will update the referenced books. 4. A pink sticker was placed on the name plate outside each resident's room who had an order for [REDACTED]. 5. A Diet Consistency Ladder was created which listed appropriate foods to be provided to residents who were to receive foods of modified consistency. 6. The facility established a checklist to verify compliance with all above interventions. Charge nurses will verify and sign each shift and the Assistant Director of Nursing will review daily. The Registered Nurse Weekend supervisor will review on the weekends. 7. Staff were inserviced on all the new procedures and changes referenced above. 8. The above interventions will be monitored and tracked through the facility's monthly quality assurance program meetings, and follow-up will be performed by the facility's Director of Nursing. Although the facility had implemented interventions to abate the immediate jeopardy, to ensure that these actions remain in effect and effective, the noncompliance continues, but the scope and severity is reduced to the "E" level. |
2014-07-01 |