| 60 |
BELLA TERRA OF BILLINGS |
275020 |
1807 24TH ST W |
BILLINGS |
MT |
59102 |
2016-12-15 |
367 |
E |
0 |
1 |
PSRD11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to follow the therapeutic diet that was ordered by a physician for 2 (#s 1 and 7), and failed to follow the physician ordered diet when providing snacks for one (#8) out of 19 sampled residents. Findings include: 1. Review of resident #1's diet order sheets, dated 5/6/16 and 6/30/16, showed the resident was to get both mechanical soft and pureed options at meal times. A physician's orders [REDACTED]. During an observation on 12/13/16 at 7:28 a.m., resident #1 was sitting in the Mountain View dining room waiting for her breakfast. She was served scrambled eggs and hot cereal. Staff left her sitting at the feeding assist table for a period of time after she appeared to be done eating. The resident consumed less than 10% of her meal. The staff members failed to offer her pureed eggs as a substitute, as the doctor's order showed. During an observation on 12/13/16 at 11:46 a.m., resident #1 was sitting in the Mountain View dining room, waiting for her lunch. Staff served her pureed carrots and mashed potatoes with gravy. The facility failed to offer her the mechanical soft diet prior to serving her the pureed carrots. During an interview on 12/13/16 at 12:00 p.m., staff member Z was asked why resident #1 received a pureed diet without getting mechanical soft textured food first. The staff member stated the resident had been receiving pureed meals. When the staff member was asked about the breakfast meal, and was reminded that the resident was only given mechanical soft food, the staff member recognized the resident was only given one option for breakfast. The staff member explained the resident's diet card showed the resident was to receive a pureed diet. Review of the resident's diet card for 12/13/16, showed the following orders: - may need assistance - dysphagia level 3 (advanced) and dysphagia level 1 (pureed) The diet card failed to specify instructions for which diet to be given to the resident, and when a diet was to be given. The card also included documentation that the resident may need assistance, but failed to show when she needed assistance. During an interview on 12/13/16 at 2:46 p.m., staff member I stated the pureed diet was really the only logical option for the resident, based on her age. Staff member I failed to explain why he thought two diets were ordered, and focused on why a pureed diet was the better option for the resident. During an observation and interview on 12/14/16 at 9:00 a.m., a family member stated resident #1 was a good eater, and that the resident would not eat pureed food. The family member stated the resident ate the mechanical soft diet well. The family member also stated they had requested ice cream be offered at meal times, along with mashed potatoes, because the resident would always eat those two foods. They were some of her favorites. The family member stated the diets were a problem with the facility because there was a staff change over and sometimes the resident just doesn't get the assistance she needs. During the interview, the resident was observed eating a cookie, broken into small pieces. The resident didn't appear to be having any struggles with eating the cookie. The resident was observed to need time to eat her snack, but was able with cuing from her family member. 2. Resident #8 was admitted to the facility with [DIAGNOSES REDACTED]. A review of the resident's Quarterly MDS, with an ARD of 9/21/16, showed the resident was cognitively intact, with an BIMS of 15. A review of residents #8's Physician Order, dated 9/21/16, showed, ST swallow eval (sic)completed. Patient appropriate for mechanical soft diet with chopped meat and nectar thick liquids. Pills to be given whole in pureed (pudding, applesauce). Patient swallow improves when completing chin tuck strategy. A review of resident #8's Physician Recapitulation sheet, dated (MONTH) (YEAR), showed, Thickened Liquids, nectar consistency, diet, mechanical soft diet with chopped meat. During an observation on 12/12/16 at 11:11 a.m., On resident #8's bed were four bags of Lays potato chips. Two of the bags were empty and placed inside an empty gray wash basin. The two remaining bags were full laying at the foot of the resident's bed. During an interview on 12/13/16 at 11:24 a.m., staff member G stated residents on altered therapeutic diets should receive snacks which are approved for the altered diet. The staff member stated potato chips were not an approved snack for a resident on a mechanical soft diet. A review of the facility's Dysphagia Diet, NDD Level 2, showed, The dysphagia diet is a transition from the pureed diet and requires the ability to chew and tolerate mixed textures. Foods are soft and moist. At times pureed versions of the menu items must be served to ensure integrity of the Dysphagia Diet. The Dysphagia Diet in the IMPAC Menu, showed, Food Groups: Desserts, avoid: Dry, course cakes and cookies. Potatoes and Starches: avoid: Potato skins and chips. During an observation on 12/13/16 at 11:30 a.m., resident #8 was in his bed. He had one empty bag of potato chips by him in his bed, and one unopened bag of potato chips on his bedside table. During an interview on 12/13/16 at 11:30 a.m., staff member N stated resident #8's favorite snack was potato chips and licorice. The staff member stated she knew resident #8 was on nectar thick liquids, but was not aware of him being on an altered diet. Staff member N stated the CNA kiosk (electronic system for documentation) showed the diets ordered for the residents, and it would also be posted on the white board at the Rimview nurses' station. During an interview on 12/13/16 at 11:35 a.m., staff member O stated she was aware resident #12 was on nectar thick liquids, but was not aware of him being on an altered diet. The staff member stated she was not aware the resident could not receive certain foods off the snack cart. Staff member O stated the refrigerator had a list of snacks approved for residents on altered diets, and for the type of altered diet, but the list did not show who was on altered diets. Staff member O stated she could look it up in the CNAs kiosk, or it might be on the white board in the report room. The staff member stated the last training she attended on altered diets was at last months, monthly training. During an observation on 12/13/16 at 11:49 a.m., staff member P gave resident #8 his medications. The staff member offered the medications to the resident whole, with thickened juice to swallow the medications. The resident started to cough. Staff member P offered another sip of thickened juice, and the resident stopped coughing. The resident's medication's were not administered with a pureed food item, such as applesauce or pudding, as the provider ordered. During an interview on 12/13/16 at 11:50 a.m., staff member P stated he was aware resident #8 was on thickened liquids, but did not know to administer his medications with a pureed food to swallow them. The staff member stated the MAR did not indicate the need to give resident #8 his medications with pudding or applesauce. Staff member P stated the resident had always taken his medications without pudding or applesauce. He stated the resident would cough at times after taking his medications. Staff member P stated he was not aware resident #8 was on an altered diet. He stated the resident would eat the snacks of his choice, and he could be very demanding for the type of snack he wanted. During an interview on 12/13/16 at 11:59 a.m., staff member M stated he was not aware of a specific diet change for resident #8. Staff member M stated he knew resident #8 was on nectar thick liquids, but was not aware of an altered diet, and snack options. Staff member M reviewed resident #8's record and found the diet order for mechanical soft diet with chopped meats and thickened liquids, and pills with puree. Staff member M stated the medications should have been ordered in the MAR. Staff member M stated it was the responsibility of the charge nurse to review all new orders and put the orders in the electronic medical record. Staff member M stated it did not appear the order for resident #8 was put in the record accurately. The staff member stated, by not providing the correct diet to a resident with dysphagia, it could have a negative result of choking, aspiration and/or pneumonia. He said if a resident had a specific snack preference, which conflicted with his diet order, the care plan would reflect that preference. During an interview on 12/13/16 at 12:10 p.m., staff member R stated she was aware resident #8 was on nectar thick liquids, but did not realize he was on an altered diet. The staff member stated she would know if the resident was on an altered diet, and what were the approved snack choices for the resident, by reviewing the white board at the nursing station. She could also look at the snack list on the refridgerator. Staff member R stated the snack cart did not have a list of approved snack alternatives for residents with altered diets. She stated it would be nice if the cart had a list of the residents receiving altered diets, and what would be an appropriate snack for them. An observation on 12/13/16 at 12:19 p.m., showed the snack cart located on Rimview had a blue cooler filled with ice, and on the second shelf a tray filled with snack options. The options on the tray consisted of Famous Amos chocolate chip cookies, Ritz Bits cheese crackers, peanut butter crackers, Fig Newtons, plain Lays Potato chips, and sugar free sugar waffle cookies. During an interview on 12/13/16 at 12:28 p.m., staff member G stated when an diet change was ordered by the physician, the nurse would take the order, enter the order into the electronic health record, then would provide her with the pink slip with the new diet order. The staff member stated she would take the diet order, and update the resident's diet ticket in the kitchen. Staff member G stated she prepared the snack options on the snack cart. Staff member G stated the snack carts did not have a list of diet alternatives or show which resident's receiveed an altered diet. She stated the resident refrigerators on the each unit had a list of alternate diets, and showed what was an approved alternative, per the diet. The refrigerators were stocked with snack options, such yogurts, applesauce, and puddings. Staff member G stated it was important for staff to follow the diet order to prevent a resident from choking or aspirating. The staff member stated resident #8 had a preference for potato chips. She stated the potato chips were not on the approved dysphagia diet. She stated resident #8 could get demanding about having his snack of choice (the potatoes chips). Staff member G stated the resident could deviate from his therapeutic diet, as long as the resident was aware of the risks and benefits, and it was documented on the resident's care plan. A review of resident #8's Care Plan, dated 9/29/16, showed, alteration in nutrition: Dysphagia, (resident) receives a mechanically altered diet. The interventions showed, provide diet as ordered: regular with nectar thickened liquids, report any chewing or swallowing difficulties to nurse. Offer snacks at HS and PRN. The care plan failed to reflect resident preferences for snack alternatives, such as, chips or cookies. During an interview on 12/13/16 at 12:40 p.m., staff member I stated it was the expectation of staff to follow the diet order for each resident. If the resident would like a food item not on the recommenced diet, the facility would need to educate the resident of the risk and benefits, then update the care plan. Staff member I stated if the staff did not follow the prescribed therapeutic diet, the resident could choke, or aspirate. During an observation on 12/13/16 at 3:11 p.m., staff member T brought the snack tray into resident #8's room and asked the resident if he would like anything off the snack tray. Resident #8 removed a bag of potato chips from the tray. During an interview on 12/13/16 at 3:15 p.m., staff member T stated she was not aware resident #8 was on an altered diet. Staff member T stated she was not aware of which residents had an altered diet, and may need a snack alternative. During an interview on 12/13/16 at 5:59 p.m., staff member D stated it was the expectation of staff to know what diets were ordered for residents. Staff member D stated the CNAs could look up what type of diet a resident was on, before passing snacks. The nurses had the orders in the electronic medical record. She stated there was a list on the refridgerator of the different altered diet snack options available for residents. It was the expectation of staff to follow the diet orders for residents as prescribed by the physician. During an observation on 12/14/16 at 4:06 p.m., resident #8 was eating Famous Amos chocolate chip cookies, while laying in bed. The head of the bed was up at 30 degrees, which was common for a person with a risk of aspiration. A review of the facility's policy and procedure titled, Therapeutic Diets, showed, Therapeutic diets, ordered by the health care provider, are supported in the community. Residents are encouraged to follow their prescribed diet; however, resident compliance cannot be ensured . 2. The community supports the following diet consistencies: a. Mechanical Soft/Soft to Chew Consistency served in ground of soft form . 5. Notify the Food Service leadership, in writing, of resident's dietary order. 6. Add the resident's name and diet to the Diet Roster. (The Diet Roster was a list of all residents and their specific diet as ordered by their health care provider). 7. Post the Diet Roster in the kitchen and in the dining areas. 8. Update the Diet Roster as needed with any diet changes (DON and Dietary Manager). 9. Add new residents to the Diet Roster immediately upon admission. 10. Maintain all diet orders received from the resident's health care provider in the resident's file. 11. Provide education to nursing and culinary staff regarding special diets. 12. Provide education to residents with special dietary needs and encourage compliance. 13. Provide supervised dining for residents with pureed foods and/or thickened liquids. A review of the facility's Suggested Snacks, for therapeutic diets, showed, Mechanical Soft Diet: Banana (ripe), Canned Fruit (soft), Cereal (No Raisins) Milk, Soft Cookies (No Nuts or Raisins), Fruit Juice, Grahan (sic) Crackers, Cottage Cheese, Applesauce, Pudding, Ice Cream, Jello, Yogurt, Milkshake, Vanilla Wafers, Cheese and Crackers, Sandwiches (Meat salad, P&J). 3. Review of resident #7's Care Plan, dated 9/13/16 to present, showed the resident was lactose intolerant. The interventions showed the resident would be on a lactose-free diet. Review of resident #7's Treatment Record, dated (MONTH) (YEAR), showed the resident diet to be regular lactose-free. Review of resident #7's Dining Card, dated 12/13/16, showed the resident was lactose intolerant. Review of Resident #7's Physician order [REDACTED]. During an observation on 12/13/16 at 11:30 a.m., resident #7 was served tuna casserole, pickled beets with a lettuce garnish, and ice cream for dessert. The resident ate greater than 50 percent of her tuna casserole, and 100 percent of her ice cream. The tuna casserole and ice cream contained lactose. During an interview on 12/13/16 at 12:10 p.m., staff member G stated that at the current time, they did not have any residents on a lactose free diet. During an interview on 12/13/16 at 12:25 p.m., staff member H stated the tuna casserole, served to resident #7, contained cream of mushroom soup, milk, and cheese. During an interview on 12/13/16 at 2:45 p.m., staff member I stated resident #7 had always been on a lactose free diet. He had also stated the Registered Dietitian would be the one who would update the interventions on a resident's care plan. During an interview on 12/13/16 at 3:00 p.m., staff member J stated resident #7 had a [DIAGNOSES REDACTED]. She also stated the resident was lactose intolerant, and noted the resident had been served ice cream with her lunch. Review of the facility's Lactose-Free Diet guideline, showed all lactose products must be eliminated, which would have included foods that would have been prepared with milk. The guideline also showed food groups that would contain lactose such as: - Milk - Cheese - Ice cream - Cream soup, canned, and dehydrated soup mixes containing milk products Review of the facility's tuna and noodles recipe from the Food for 50 book, showed the recipe contained cheese, canned cream of mushroom or celery soup, and milk. Review of the facility's policy on therapeutic diets, dated 11/10/16, showed that individuals who would present with lactose intolerance should avoid dairy products. |
2020-09-01 |