| 664 |
HERITAGE OF BEL AIR |
285089 |
1203 NORTH 13TH STREET |
NORFOLK |
NE |
68702 |
2019-06-24 |
689 |
G |
0 |
1 |
2H0G11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D7 Based on observation, interview, and record review; the facility failed to implement interventions to prevent potential choking episodes for Resident 41. The sample size was 1 and the facility census was 84. Findings are: Review of a Progress Note dated 5/12/19 revealed at 12:50 PM Resident 41 began coughing during lunch. The resident had increased difficulty breathing and talking. The resident shook no when asked if the resident could talk. Back blows were performed with no improvement. The resident became unresponsive and cyanotic (bluish discoloration usually caused by low oxygen levels) with fixed pupils. The resident's chin was lifted, to obtain optimal airway, and the resident then coughed and was able to take breaths at that time. The resident's physician and Power of Attorney (POA) were notified per telephone. The resident's POA requested the resident's current diet remain unchanged. Review of a ST (Speech Therapy) Daily Treatment Note dated 5/14/19 revealed ST recommended a mechanical soft diet with extra sauces/gravies and no raw fruits or vegetables. Review of a Progress Note dated 5/14/19 at 10:30 PM, revealed Resident 41 was offered a ground meat sandwich. The resident coughed and had strider (high-pitched, wheezing sound caused by disrupted airflow) type respirations. The nurse attempted the [MEDICATION NAME] maneuver and performed back blows with no change. The resident began to have cyanosis to the lips, ears, and nail beds. The resident became unresponsive to tactile (sensory stimulation involving touch) and verbal stimulation. The resident was transferred out of the wheel chair, to the floor, rolled on side, and back blows were performed again. Oxygen was started and the resident started coughing. Review of a Progress Note dated 5/17/19 at 8:50 AM revealed Resident 41 had another choking/wheezing episode at the breakfast table. The wheezing lasted for a few seconds and then the resident stopped wheezing and took a drink of water. The resident did this a few times at the breakfast table, and then had more wheezing when seated in the recliner in the day area. The resident became cyanotic in the face. Oxygen was applied and a breathing treatment was completed. Review of a Progress Note dated 5/20/19 at 10:00 AM revealed Resident 41 choked on Cream of Wheat cereal. The Cream of Wheat cereal was stuck to the resident's throat. The resident was encouraged to drink more fluids and was able to drink the fluids. The staff were educated to add some milk to the Cream of Wheat cereal to help with swallowing. Review of Resident 41's current Care Plan revealed the Care Plan was updated on 5/20/19 to include the following interventions related to the resident's choking episodes: - Monitor for signs and symptoms of aspiration (sucking food into the airway), - All staff were informed of special dietary and safety needs, - Check the resident's mouth after meal for pocketed food and debris, - Follow the diet as prescribed with no raw fruits and vegetable, - Monitor for shortness of breath, choking, labored respiration, and lung congestion, and - Refer to speech therapist for swallowing screen/evaluation as needed. Review of a Progress Note dated 5/24/19 at 12:21 PM revealed Resident 41 was seated at the dining room table and had an extreme episode of wheezing/food stuck in the resident's throat. Back blows and [MEDICATION NAME] maneuver were performed with no change. Sips of water were given to clear the throat with no relief. The resident went unresponsive and turned blue/grey. The resident was transferred to bed and oxygen was started. Once the resident was laid down, color came back slowly and the resident coughed numerous times. Review of a ST Daily Treatment Note dated 5/27/19 revealed it was reported that Resident 41 had an extreme choking episode over the past weekend where the resident's airway was blocked for several minutes. The nurse stated that the meal provided during the incident did not have extra sauces/gravies. Resident 41's Therapist Progress and Updated Plan of Care dated 5/28/19 identified a list of foods to avoid to prevent potential choking while on the mechanical soft diet. Food items to avoid included rice, corn, cheese, bread, pie crusts, cookies, raw fruits, raw vegetables, potato chips, pineapple, sticky foods (such as chewy candies), lettuce, and dry cereal. Review of a ST Daily Treatment Note dated 5/30/19 revealed Resident 41 had oral residue post swallow of ground meats. On 6/20/19 at 12:20 PM Resident 41 was seated in the dining room for lunch. The resident was served a lettuce salad with dressing, which was placed in front of the resident ready for consumption. Interview with the Assistant Dietary Manager on 6/20/19 at 12:20 PM confirmed Resident 41 had dietary restrictions which included no raw fruits or vegetables. The Assistant Dietary Manager confirmed the resident should not have been served a lettuce salad. Resident 41 was observed on 6/24/19 from 9:20 AM to 9:37 AM. The resident was seated in the dining room eating breakfast. The resident was served hot cereal with milk, ground meat, and scrambled eggs with a variety of drinks. The resident ate independently. After eating, the resident was transferred from the dining room table to a recliner in the day area by Nursing Assistant (NA)-C and NA-L. The resident's mouth was not checked to ensure no food items were pocketed. Interviews with NA-B, NA-L, and Registered Nurse-M on 6/24/19 from 9:32 AM to 9:37 AM, confirmed Resident 41's mouth was not checked after breakfast on 6/24/19. Further interview confirmed the staff did not check Resident 41's mouth after meals. Review of Resident 41's Medical Record on 6/24/19 revealed no evidence to indicate oral inspections were completed after meals to check for pocketed food items. |
2020-09-01 |