| 21 |
BENEFIS SENIOR SERVICES |
275012 |
2621 15TH AVE S |
GREAT FALLS |
MT |
59405 |
2019-07-11 |
689 |
G |
0 |
1 |
01HJ11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary supervision and assistance needed for a resident who had swallow deficits and a choking episode, which required staff to provide the [MEDICATION NAME] Maneuver, for 1 (#89) of 42 sampled residents, and failed to implement interventions for ongoing risks related to choking. Findings include: During an observation on 7/8/19 at 4:50 p.m., in the resident dining room, resident #89 was left unattended in the back of the dining room, behind the serving table, in his wheelchair. Resident #89 was positioned behind a bedside table. Resident #89, with his tongue thrusting out, was coughing on his thickened water. No staff came to check on the resident. He then set his drink down on the bedside table to use his clothing protector to wipe his face and wheeled out of the dining room. A staff member wheeled resident #89 back into the dining room entrance and resident #89 proceeded to go to a different table and took his soiled clothing protector off and set it on another resident's place setting and drinks. Resident #89 returned to his bedside table where two bowls of pureed food and his drink were waiting. Resident #89 fed himself with an adaptive spoon, and due to his frequent tongue thrusting, he had to place the spoon far back in his mouth in order to empty the spoon. Resident #89 resorted to picking up the bowl and placing it against his lips to scoop the food with the adaptive spoon without taking a break, or switching to a drink in between bites of food. No staff were directly supervising or encouraging resident #89 to slow down or alternate food with liquids. Record review of resident #89's nursing note and alert, dated 7/4/19, showed, Res was in dining room sand resident chokking, he was unable to clear his airway and started turning blue. Res was lifted out of WC and [MEDICATION NAME] was started. After three deep thrusts I was able to dislodge te object res swallowed it so I was unable to see what it was. Res had been seen at res table by the pole, appeared he was taking food. He is currently resting in his room. (sic) During an observation and interview on 7/10/19 at 2:40 p.m., staff member L showed resident #89's diet card. The 1:1 for dining intervention was written on the bottom right corner of the diet card. This notation was covered by a yellow post-it note labeled puree. Staff member L stated that the staff members serving meals may not have seen the intervention, because of where the post-it was placed on the diet card. Staff member L stated the discipline that implemented the intervention was responsible for updating the diet cards. During an interview on 7/10/19 at 11:38 a.m., staff member N stated, Staff, as a whole, periodically keeps an eye on (resident #89). During an interview on 7/10/19 at 2:30 p.m., staff member O stated, an incident would create an alert in the Kardex of the electronic medical record. She stated therapy, dietary, nursing, and all management would receive an alert in the case of a choking incident. During an interview on 7/11/19 at 8:33 a.m., staff member M stated she was not present for the choking incident that occurred on 7/4/19, but heard resident #89 had taken another resident's bread and choked on it. Staff member M stated all staff are to keep a close eye on resident #89 as he wanders. Staff member M had noticed that resident #89 would push the adaptive spoon so far back into his mouth, he would gag on it, when eating too fast. Resident #89 coughed a lot but usually forcefully coughed enough to clear his throat on his own. Staff member M stated the protocol for notification after performing the [MEDICATION NAME] Maneuver was to notify management, doctor, resident representative, dietician, and therapy. Staff member M stated the expectation of the nurse is to implement interventions necessary to keep the resident safe, while waiting for a call back from the provider. Staff member M stated management, therapy, and the oncoming shifts would see an alert in the electronic medical record notifying staff of the incident. During an observation on 7/11/19 at 9:06 a.m., resident #89 was left unattended in the back of the dining room, behind the serving table, in his wheelchair. Resident #89 was positioned behind a bedside table. Resident #89 had three bowls of pureed food and a drink. Resident #89 was using an adaptive spoon and had difficulty removing the food from his spoon. Resident #89 spilled food onto his clothing protector, scooped the food off, and ate it. Resident #89 then placed the spoon far back into his throat and gagged. Resident #89 tipped his head back and continued to cough, moan, and made a wet, gurgling sound with his tongue thrust out. Staff member O came over and adjusted the resident's clothing protector and told him he was okay. Staff member O walked away; no one was directly supervising resident #89. Record review of resident #89 Speech Therapy note on 7/8/19, showed a recommendation of 1:1 supervision for consuming food/liquids. High Choking/Aspiration Risk. No documentation was found for notification of the physician, resident representative, or assessment of resident #89's wellbeing related to the choking. |
2020-09-01 |