cms_GA: 1951
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1951 | PRUITTHEALTH - ATHENS HERITAGE | 115509 | 960 HAWTHORNE AVENUE | ATHENS | GA | 30606 | 2018-07-26 | 692 | D | 1 | 1 | GMU011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on closed record review, interview, and review of facility policy, the facility failed to ensure one of four residents (R) (R#152) reviewed for nutrition was screened and assessed by the Dietary Manager and Dietitian in accordance with facility policy and served the correct diet. These failures placed the resident at risk for choking, aspiration (inhalation of food, stomach acid, or saliva into the lungs), weight loss and exacerbation of other nutritional problems. Findings include: Closed record review revealed R#152 was admitted to the facility on [DATE] following hospitalization ; the resident was discharged home on[DATE]. R#152 was not in the facility during the survey. Review of a document titled Notification of Admission Form dated 7/3/18 revealed the resident had been living with her son prior to admission with plans to return home after rehabilitation. [DIAGNOSES REDACTED]. The reason for the resident's hospitalization was abdominal pain for one to two weeks with nausea and vomiting. The resident was also newly diagnosed with [REDACTED]. The resident was documented as being on a mechanical soft diet. Review of the resident's Baseline Care Plan dated 7/3/18 indicated the resident's goal was to increase strength so she could go home. The resident was documented as having experienced an activity of daily living (ADL) decline related to a stroke. The goal was for the resident to improve ADL function to maintain independence through the next 30 days. The care plan identified a problem of diabetes and risk for hyper or [DIAGNOSES REDACTED]. The goal was for the resident's blood sugar to be maintained to the next 30 days. The nutrition section of the care plan was blank, it had not been filled out. The Admission/Nursing Observation Form dated 7/3/18, under the section titled Eating revealed the resident was on a mechanical soft diet and she had a poor appetite. Review of a document titled Hospital Patient Visit Report dated 7/3/18, under Instructions documented the resident's diet was resume previous diet. Review of the initial physician's orders [REDACTED]. Review of the facility form titled Dietary Communication Form dated 7/3/18 at 3:30 p.m. indicated the resident was on a regular consistency diet. Review of a physician's telephone order dated 7/4/18 revealed orders for speech therapy evaluation and treatment as indicated. The resident was to be treated for [REDACTED]. Review of facility document titled SAFE Swallowing Ability and Function Evaluation form dated 7/4/18 indicated the resident had moderate deficits in oral and pharyngeal phase with mastication bolus and decreased swallowing and was at increased risk for aspiration. The document indicated the resident's diet was changed from regular consistency to mechanical soft. The Dietary Communication Form dated 7/4/18 at 2:30 p.m. indicated the resident was be served a mechanical soft diet with chopped meats. The next dietary communication form (undated), undated documented the resident was to receive a soft mechanical diet. On 7/6/18 the Speech Therapist recommended a diet change to mechanical soft with pureed meats; a telephone order was written for the texture change. The Yearly Weight Record Form indicated the resident was weighed once on 7/7/18. On this date the resident's weight was 125.8 pounds. The resident was 5'3 tall. Review of the Skilled Daily Notes documented by nursing staff revealed there were no notes related to the resident's diet, not receiving the right foods, or any other nutritional/dietary concerns being raised by the resident or her family. The entire closed record for R#152 was reviewed. There was no documentation of a nutrition screening or assessment in the record. The only documentation from dietary consisted of a food preference form completed on 7/6/18. The resident was at risk for adverse nutritional outcomes related to [DIAGNOSES REDACTED]. The family of R#152 was interviewed on 7/25/18 at 11:30 a.m. over the phone. The Family of R#152 stated the resident was served a hamburger the first meal after she was admitted to the facility. He stated another family member was with the resident and stopped the resident from eating it. The Family of R#152 also stated the resident had received mechanically altered foods in the hospital and she was unable to eat regular food. The Family of R#152 further stated the family made the staff (speech therapist and nursing) aware of the situation so the diet could be corrected. The Family of R #152 added the resident received a second serving of regular meat the next meal after the diet order problem had been brought to the attention of staff on 7/3/18. Family of R#152 stated the resident had a stroke and it was unsafe for her to eat regular food. The Family of R#152 also stated a nurse was notified of the wrong diet following the second meal. He stated the diet texture was corrected after the second meal when the resident was served regular meat. The following staff interviews verified the resident was not screened or assessed for nutritional status and was served the wrong diet texture initially: -Licensed Practical Nurse (LPN) GG was interviewed on 7/25/18 at 2:45 p.m. in the Family Dining Room. LPN GG stated one of R#152's family members was with the resident most of the time during days and evenings over the course of her stay. LPN GG stated there had been several issues raised about the resident's diet. LPN GG stated, It seemed like a miscommunication with family. At first, they wanted pureed, then mechanical soft, and then pureed foods. LPN GG stated the hospital orders called for a mechanical soft diet to be served when she was admitted on [DATE]. -Certified Nurse Assistant (CNA) HH was interviewed on 7/25/18 at 3:40 p.m. in the Family Dining Room. She stated she remembered the resident and family, stating she did not remember any concerns regarding the resident's diet. CNA HH stated she remembered the family bringing the resident food to eat during her stay. -The Registered Dietitian (RD) was interviewed on 7/25/18 at 3:55 p.m. in a conference room. The RD explained how the nutrition screening and assessment process worked. She stated a nutrition screening/assessment was completed by the Dietary Manager and herself. She stated the Dietary Manager completed the first page of the document (nutrition screening) as well as a food preference form within five days of admission and she completed the second page (nutrition assessment) later. The RD stated she completes the assessment for high risk residents (those with wounds, on tube feedings, and on [MEDICAL TREATMENT]) within seven days of admission. And she completes the nutrition assessments for all other residents in the order they were admitted . The RD added there was no deadline for completing nutritional assessment for newly admitted residents. She reviewed the resident's closed record and verified there was no nutrition screening or nutrition assessment in the record. The RD stated, I do not remember assessing her. I probably would not have seen her if she was not at high risk. The RD stated there were a lot of residents admitted for rehabilitation with short stays. The RD indicated she was not in the facility the first week in (MONTH) (YEAR); however, was in the facility on 7/12/18 or 7/13/18. The RD verified she had not assessed the resident and did not have any direct contact with, or firsthand information about the resident. The RD confirmed according to the facility's nutritional assessment policy this resident's nutritional assessment should have been completed within 14 days of admission Continued interview with the RD revealed she reviewed the resident's closed record and stated the Admission/Nursing Observation Form dated 7/3/18, indicated the resident was prescribed a mechanical soft diet in the hospital and that was her diet order when she was admitted . The RD reviewed the handwritten physician's orders [REDACTED]. She stated, I don't know where that (regular diet order) came from. -The Director of Nursing (DON) was interviewed on 7/25/18 at 4:15 p.m. in a conference room across from the Family Dining Room. The DON indicated she had been in her position as DON for about a week and prior to that, she was the Unit 1 Manager (the unit where R#152 had resided during her stay). The DON verified the Admission/Nursing Observation Form dated 7/3/18, indicated the resident's diet order was mechanical soft. The DON reviewed the handwritten physician's orders [REDACTED]. The DON stated she was aware the resident was served a regular diet which included a hamburger on 7/3/18 and verified the resident's family had spoken with her about it. The DON also stated the resident was served regular fish (not mechanical soft or pureed) and the resident's family was also upset about that, saying it was not soft enough. The DON further stated the resident's diet order was changed several times during her stay, to pureed, mechanical soft, and then to mechanical soft with pureed meats. -Licensed Practical Nurse (LPN) II was interviewed on 7/25/18 at 5:04 p.m. in the conference room across from the Family Dining Room and verified she was the nurse who documented a regular diet on the initial physician's orders [REDACTED]. LPN II retrieved a document titled Patient Visit Report, dated 7/3/18 and it read under diet: Resume Previous Diet. The diet order was not clear; the resident was on a mechanical soft diet while in the hospital and prior to her stroke and hospitalization , had eaten regular foods. LPN II stated she did not know what the texture was supposed to be, so she documented regular texture on the orders and told the admitting nurse on the 100 Unit, the texture needed to be clarified. LPN II stated she was helping on the 100 Unit and she was not the admitting nurse for the resident. She stated her position was Unit Manager of the 200 Unit. The facility was unable to provide documentation of the need to clarify the diet order or evidence that this was communicated. -The Speech Therapist (ST) was interviewed on 7/26/18 at 9:43 a.m. in his office. He stated he was not the ST who worked with the resident; this staff member was not working. However, the ST was able to access the ST records and opened the initial ST evaluation completed on 7/4/18. He stated R#152 was prescribed a mechanical soft diet with chopped meat on 7/4/18, the day after admission. The ST stated the evaluation indicated the resident experienced frequent coughing and throat clearing during the ST evaluation. He further stated the resident experienced moderate oral retention or residue after she swallowed. When asked about the diet order that read Resume Previous Diet he stated the diet should have been clarified by the nurse. ST stated the consistency of the diet order should have been documented under the hospital discharge orders. The ST stated, She would be at risk eating regular hamburger with the issues documented in the assessment. The ST stated the resident's meat needed to be chopped into bite sized pieces. -The Dietary Manager was interviewed on 7/26/18 at 11:11 a.m. in the dining room and verified she did not have a copy of the nutrition screening form and did not know if she had completed it. The Dietary Manager also stated she usually completed the food preference form and nutrition screening at the same time. Review of the facility document titled Nutritional Screening and Assessment - Food Preferences Policy revised on 11/21/16 indicated it was the policy for residents to receive an initial nutritional screening and comprehensive nutritional assessment upon admission. Under procedure, the dietary manager was directed to review the nursing admission assessment form and complete the initial screening portion of nutrition screening and assessment form within five days of admission for all residents. The Registered Dietitian was to complete the nutritional assessment within 14 days of admission if the facility was a joint commission facility. The resident resided in the facility 17 days and was not screened by the Dietary Manager or assessed by the Dietitian. | 2020-09-01 |