| 1139 |
ARBOR CARE CENTERS-O'NEILL LLC |
285108 |
PO BOX 756, 1102 NORTH HARRISON |
O' NEILL |
NE |
68763 |
2016-11-21 |
309 |
J |
0 |
1 |
QLXM11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09 Based on observation, interview, and record review; the facility failed to provide diet modifications to prevent potential aspiration for Resident 57 and to provide assessment and monitoring for Residents 31 and 39 who were receiving [MEDICAL TREATMENT] (A method used to treat kidney disease by clearing metabolic waste products, toxins, and excess fluid from the blood). The sample size was 43 and the facility census was 68. Findings are: [NAME] Review of the facility policy and procedure titled Thickened Liquids with a revision date of 3/9/15 revealed the following: - Thickened liquids will be served to residents as ordered by the physician. - The Food Services Director will record the ordered consistency on the resident's tray card. - Pre-thickened liquids will be used whenever possible. - For beverages which must be thickened, the beverage will be thickened by the dietary staff prior to leaving the kitchen. Review of an undated facility policy titled, Thickened Liquids revealed there were 3 types of thickened liquids: -Nectar Consistency- a consistency of nectar, or milkshakes; -Honey Consistency- a consistency of honey and thicker than nectar consistency; and -Pudding Consistency- the thickest of the three consistencies and the consistency of pudding. B. Review of a Hospital Progress Note dated 9/14/16 revealed Resident 57 was admitted to the hospital on [DATE]. Further review revealed Resident 57 aspirated after being admitted to the hospital with [REDACTED]. Review of Resident 57's Progress Note dated 9/21/16 at 4:51 PM revealed the resident returned to the facility from the hospital on [DATE] at 2:15 PM. Review of Resident 57's Order Summary Report revealed an order for [REDACTED]. Review of a Telephone Order dated 9/23/16 revealed Resident 57's diet was changed to a full-liquid diet with liquids thickened to honey consistency due to difficulty swallowing. Review of Resident 57's Progress Note dated 9/23/16 at 1:51 PM confirmed Resident 57's diet was changed to a full liquid diet with honey consistency. Review of the Resident 57's Progress Note dated 9/24/16 at 2:57 PM revealed after lunch the resident became more gurgly and wet sounding and was unable to cough or clear throat. Oxygen saturations (the concentration of oxygen in the blood, normal levels are 95-100 percent (%)) were checked and in the low 80 %. The resident was moaning and appeared to be in respiratory distress. Upon assessment the resident's lung sounds were very wet with audible wheezes heard. The facility was unable to get the resident's oxygen saturations above 81-82% on 3 Liters of oxygen and the resident's extremities were cool to the touch. The resident was transferred to the hospital. Review of a Hospital Progress Note dated 9/25/16 revealed the resident came into the hospital hypoxic (a condition in which the body or a region of the body is deprived of oxygen) on 9/24/15. The resident was found to have a mouthful of food and once this was suctioned the oxygen saturations improved. Review of the Hospital Diagnostic Imaging report dated 9/25/16 showed infiltration (presence of a substance more dense than air) at the left lung base. Review of Resident 57's current Care Plan with a revision date of 9/26/16 revealed the resident was on puree liquefied diet which was honey thickened in consistency. Review of Resident 57's Progress Note dated 9/27/16 at 3:35 PM revealed the resident returned to the facility from the hospital on [DATE] at 12:50 PM. Review of Resident 57's Progress Note dated 9/28/16 at 2:09 PM confirmed the resident's diet upon return from the hospital was to continue the full-liquid diet with honey thick consistency. Review of Resident 57's Progress Note dated 10/13/16 at 1:54 PM revealed the resident had a choking episode at lunch and vomited. Review of Resident 57's diet cards dated 11/15/16 and 11/16/16 indicated the resident was on a liquefied puree diet with nectar thick liquids, although the actual diet order was for honey thick consistency full-liquid diet. Review of the communication board posted in the kitchen on 11/15/16 at 12:30 PM revealed a note regarding Resident 57 which indicted the dietary staff were not to thicken the resident's liquids for meals. Observations of meal preparation revealed the following: -On 11/15/16 from 11:18 AM to 11:45 AM, Cook-X pureed the turkey. An unmeasured amount of broth and milk was added to the turkey to further liquefy the food. Cook-X then pureed the stuffing and added an unmeasured amount of broth and milk to the stuffing to further liquefy the food. No recipe was used. -On 11/15/16 at 11:51 AM Dietary Aide (DA)-Y prepared pureed cake using a recipe. Then DA-Y prepared the liquid cake by adding an unmeasured amount of milk. During an interview on 11/15/16 at 12:30 PM, Cook-X- stated Resident 57 was on an all liquid diet with thickened liquids. Cook-X stated the dietary department had the resident's dietary consistency listed as nectar thick, but nursing would tell them the resident should receive honey thick consistency so Cook-X did somewhere in between. Cook-X stated this was so the liquids did not set up too much, which was difficult for the resident to swallow. Further interview revealed the nursing staff could add thickener at the table if the nursing staff felt the drinks needed more. Cook-X confirmed recipes were not used when preparing the puree and liquids diets. Nursing Assistant (NA)-Q was observed assisting Resident 57 with the noon meal on 11/15/16 at 12:50 PM. The resident was observed to have a small cough after taking drinks of the liquefied turkey, stuffing, and cake. During an interview on 11/15/16 at 3:00 PM, Cook-Z revealed dietary staff had been notified by nursing that they (dietary) were not to thicken Resident 57's liquids anymore because the liquids were getting too thick and instead nursing would thicken them at the table before giving them to the resident. Cook-Z stated the resident was supposed to receive honey thick liquids but confirmed the diet card listed nectar thick consistency. During an interview with the Dietary Manager (DM) on 11/15/16 at 3:30 PM, the DM confirmed there were discrepancies in Resident 57's diet consistency regarding whether it should be nectar or honey thick, but confirmed it was to be honey thick. The DM confirmed the dietary staff would not thicken the drinks all the way (to honey thick) because the drinks were getting too thick so dietary would leave them thinner and then nursing could adjust them as needed. During an interview on 11/15/16 at 4:05 PM, NA-Q was unsure what consistency Resident 57's liquids should have been at the noon meal on 11/15/16. NA-Q thought the liquids were to be nectar thick but was not sure. During further interview NA-Q revealed the kitchen thickened the liquids, but nursing would adjust the liquids at the table if they felt it was too thick or too thin. During an interview with NA-AA on 11/15/16 at 4:32 PM, NA-AA did not know what consistency Resident 57's liquids were supposed to be and stated the kitchen thickened them. NA-AA was not aware of nursing being responsible for thickening the resident's liquids instead of the dietary staff. NA-AA was not sure if Resident 57's diet was actually a liquid diet or more a puree consistency that could be drank. NA-AA indicated the diet served to Resident 57 sometimes had chunks in it', like pieces of broccoli. Observation on 11/15/16 at 6:03 PM revealed Resident 57 was served a glass of non-thickened orange juice. The Administrator was notified and the Administrator indicated the orange juice would be thickened before offering it to the resident. During an interview with the Administrator on 11/15/16 at 6:29 PM, the Administrator confirmed the NA's had not had any training on thickening liquids and the different diet consistencies. Observation on 11/16/16 at 8:00 AM revealed Resident 57 was served a glass of non-thickened orange juice. Further observation revealed a container of powdered thickener setting on the table in front of the resident. Licensed Practical Nurse-H observed the non-thickened orange juice and requested a thickened glass of orange juice from dietary. During an interview on 11/16/15 at 8:45 AM, DA-W confirmed Resident 57 was provided non-thickened orange juice at breakfast. DA-W confirmed nursing had been thickening the resident's liquids and DA-W had not been notified of any changes. During an interview on 11/16/16 at 10:00 AM, NA-D was aware Resident 57 was on an all liquid diet, but thought the consistency was to be pudding thick. Observation on 11/16/16 at 12:10 PM revealed Resident 57 was served orange juice that appeared pudding thick as it was so thick that it did not spill out of the cup when the cup was tipped over. NA-P was notified and NA-P stated the liquid would be returned to dietary and a new orange juice would be requested. During interviews on 11/16/16 at 12:10 PM, NA-M and NA-P confirmed they had not had any training on thickening liquids and the different diet consistencies. The immediate jeopardy was abated to a D level on 11/16/16 at 5:30 PM when: 1) Residents receiving thickened liquids and liquefied diets were identified and diets were confirmed. 2) Dietary staff were instructed to thicken all liquids according to diet orders. 3) A plan was created to train all dietary staff members prior to them adjusting diet and/or liquid consistencies. This training consisted of education and demonstrations. Training of the dietary staff will be completed by the DM, who was trained by the Registered Dietician (RD) on 11/16/16. 4) Liquids to be thickened just prior to being sent out of the kitchen to prevent the consistency from changing. 5) Nursing staff will be in-serviced regarding policy of dietary responsibility for thickening liquids, and educated so the nursing staff can help identify incorrect diet orders. 6) A dietary communicating slip will be used for any new dietary or supplement order to improve communication between dietary and nursing. 7) Speech therapy recommendations will be given to nursing and dietary and signed by both departments. 8) Any new dietary orders will be monitored in Clinical Start-Up (a daily meeting Monday through Friday). 9) The DM, RD, Administrator, and the DON will take turns completing audits of each meal to check dietary tickets against correct diet and liquids for 2 weeks to ensure each resident on thickened liquids are receiving the accurate diet. 10) The plan of correction will be reviewed by the Quality Assurance Committee for the next 3 months. 11) Recipes are to be used whenever possible and dietary staff trained to adjust consistencies as needed as the recipes may not always produce the correct results. 12) The facility placed an order from their supplier for pre-thickened liquids. 13) The facility placed an order from their supplier for liquid thickener, which does not change consistencies over time (instead of the powdered thickener). C. Review of the facility policy titled [MEDICAL TREATMENT] Management ([MEDICAL TREATMENT]) dated 9/2013 revealed the following related to [MEDICAL TREATMENT] provided at an off-site [MEDICAL TREATMENT] Center: - Assure facility completed [MEDICAL TREATMENT] Communication form accompanies the resident to [MEDICAL TREATMENT] on treatment days, to communicate resident information and to coordinate care between [MEDICAL TREATMENT] Center and the facility. - Post [MEDICAL TREATMENT], staff to assess the [MEDICAL TREATMENT] every hour for 4 hours, documenting any bleeding, pain, redness and swelling. - Maintain and record fluid restrictions, as ordered. - Evaluate and document arteriovenous (AV- joining of an artery and a vein under the skin in the patients arm and used to access the patient's blood for [MEDICAL TREATMENT]) fistula daily for thrill (A thrill is checked by lightly placing fingertips over the fistula site and feeling for vibration of blood circulating through the fistula.) and bruit (A bruit is checked by placing a stethoscope over the fistula area and listening for blood flow.) and monitor for any signs and symptoms of infection. Evaluate central venous (CV-tubes placed in a vein in the neck, groin or back. Each central venous catheter has two openings; one takes blood from your body to be cleaned by the [MEDICAL TREATMENT] machine and the clean blood returns to your body through the other) catheter daily for signs and symptoms of infection and document. - Manage dietary restrictions as ordered. D. Review of Resident 31's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/25/16 revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident was receiving [MEDICAL TREATMENT]. Review of Resident 31's current Care Plan with revision date 8/15/16 revealed the resident was receiving [MEDICAL TREATMENT] 3 times weekly on Mondays, Wednesdays and Fridays. Nursing interventions included the following: - check access site (catheter) daily for signs of infection (redness, hardness, swelling, pain, drainage, elevated body temperature and body chills); - observe for post [MEDICAL TREATMENT] hang over-vital signs, mental status, excessive weight gain between treatments, nausea, vomiting, weakness, headache or severe leg cramps; and - 1800 milliliter (ml) fluid restriction, 480 ml at meals, 150 ml during the day and evening shifts and 60 ml on the night shift. Review of [MEDICAL TREATMENT] Communication Forms (a form completed with each [MEDICAL TREATMENT] treatment and used to communicate information and recommendations between the facility and the [MEDICAL TREATMENT] center) for Resident 31 from 10/1/16 through 11/16/16 revealed the section to be completed by the Nursing facility prior to the resident's [MEDICAL TREATMENT] treatment was missing documentation related to assessment of the [MEDICAL TREATMENT] and the resident's vital signs for the following dates: 10/3/16, 10/5/16, 10/7/16, 10/10/16, 10/12/16, 10/14/16, 10/19/16, 10/21/16, 10/26/16, 10/28/16, 10/31/16, 11/2/16 and 11/4/16. Review of Resident 31's medical record revealed no documentation to indicate assessments of vital signs and condition of the [MEDICAL TREATMENT] were completed by the facility upon Resident 31's return from [MEDICAL TREATMENT] treatments in accordance with the Care Plan and facility policy. Review of Resident 31's Treatment Administration Record (TAR) dated 11/2016 revealed the resident was to be on an 1800 ml fluid restriction per 24 hours. The resident was to receive 480 ml of fluid with each meal, 150 ml of fluid during the day and evening shifts and 60 ml of fluid on the night shift. Review of a Resident 31's TAR for 11/2016 revealed no documentation to indicate the amount of fluids the resident consumed each meal and during each shift were monitored and recorded to maintain the resident's fluid restriction. Interviews on 11/15/16 from 11:39 AM until 5:00 PM revealed the following: - NA-P was aware the resident was on a fluid restriction, however, NA-P indicated the nursing staff was no longer recording fluid intake after meals or throughout the shifts. - The Director of Nursing (DON) confirmed the Charge Nurse assigned to Resident 31 on the days the resident went to [MEDICAL TREATMENT] was responsible for completing the [MEDICAL TREATMENT] Communication Form and for assessing and documenting the resident's condition after [MEDICAL TREATMENT]. In addition, the nursing staff should be documenting the resident's fluid intake after each meal and with each shift to assure compliance with the resident's fluid restriction. E. Review of Resident 39's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. Review of Resident 39's current Care Plan with revision date 9/24/16 revealed the resident was receiving [MEDICAL TREATMENT] 3 times weekly. Nursing interventions included the following: -Check access site-catheter-AV Fistula-for signs of infection; -Diet and fluid restrictions as ordered. Review of Resident 39's medical record revealed no evidence that assessments of the [MEDICAL TREATMENT] were completed. Review of Resident 39's TAR dated 11/2016 revealed the resident was on a 2000 ml fluid restriction; however, there was no evidence to indicate the amount of fluids the resident consumed each shift was monitored and recorded. Interview with the DON and Licensed Practical Nurse (LPN)-H on 11/14/16 at 3:50 PM confirmed there was no documentation regarding Resident 39's fluid intake. In addition, the DON and LPN-H confirmed Resident 39's [MEDICAL TREATMENT] was supposed to be assessed every shift and results of the assessment were to be recorded on the TAR. Interview with DA-W on 11/15/16 at 1:07 PM revealed DA-W poured and served Resident 39's fluids for the noon meal that day. DA-W was not aware Resident 39 was on a fluid restriction. Interview with the Dietary Manager on 11/15/16 at 3:58 PM confirmed the dietary department was not aware Resident 39 was on a fluid restriction. |
2020-09-01 |