| 53 |
SANDIA RIDGE CENTER |
325032 |
2216 LESTER DRIVE NE |
ALBUQUERQUE |
NM |
87112 |
2018-03-14 |
689 |
J |
0 |
1 |
YN7D11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure that accident hazards were minimized on the locked Dementia (a general term for loss of memory and other mental abilities severe enough to interfere with daily life) unit, by failing to provide residents with the correct consistency snack. This deficient practice resulted in an Immediate Jeopardy (IJ) at a scope and severity of J being identified on 03/06/18. The facility was notified on 03/06/18 at 4:21 pm. The facility took corrective action by providing an acceptable Plan of Removal on 03/06/18 at 4:23 pm. Based on the Plan of Removal, interventions included: 1. Snack lists have been reviewed for correct diet by CNE (Center Nurse Executive) and Dietician on 03/06/18. 2. Diet orders have been provided to the nursing stations for quick review for staff on 03/06/18. 3. Staff currently working were educated on the diet order notebooks on 03/06/18, other staff will be re-educated prior to working their next shift. 4. Daily checks will be conducted for residents on snacks for correct diet by the unit manager or designee for 1 week, and then weekly for 4 weeks, and then monthly thereafter. 5. The daily checks will be brought to QAPI (Quality Assurance Performance Improvement) monthly for three months. Based on the Plan of Removal, the IJ was lifted on 03/06/18 at 4:25 pm. This resulted in the scope and severity being reduced from level J to level D. Based on observation, record review, and interview, the facility failed to ensure that residents received the correct consistency of snacks and that the resident environment was free of tripping hazards for 3 (R #s 35, 81, 97) of 3 (R #s 35, 81, 97) residents reviewed for accident hazards. This deficient practice increases the risk for falls, choking, aspiration, and/or death. The findings are: Findings for R #81 [NAME] Record review of R #81's Diet Order and Communication Form dated 11/06/17, revealed R #81's diet was changed to dysphasia puree (diet where all food has been ground, pressed, and/or strained to a consistency of a soft smooth paste) by the Speech Therapist. B. On 03/06/18 at 11:06 am, during observation in the locked Dementia Unit, R #81 was given a whole banana as a snack. C. On 03/06/18 at 2:07 pm, during observation in the locked Dementia Unit, R #81 was given half of a peanut butter and jelly sandwich as a snack. D. On 03/06/18 at 2:16 pm, during interview CNA (Certified Nursing Assistant) #1 stated that he believed R #81 was on a mechanical soft diet (foods that are chopped or soft). After checking, CNA #1 verified that R #81 is dysphasia pureed and confirmed that he did give her a peanut butter and jelly sandwich. CNA #1 also stated that residents' diet orders are communicated three ways: 1. on the diet sheets kept in the medical charts, 2. the nurses tell CNAs, 3. On the diet order slips. E. On 03/06/18 at 2:19 pm, during interview RN (Registered Nurse) #1 stated that a peanut butter and jelly sandwich is not appropriate on a pureed diet. RN #1 confirmed that CNAs should know which residents are on a pureed diet, stating that most of the CNAs are regulars, so they are well aware. F. On 03/06/18 at 2:30 pm, during interview the Dietary Director confirmed that a peanut butter and jelly sandwich is not acceptable on a pureed diet. The Dietary Director stated that the snacks will have a nutrition label put on it from the kitchen and then staff take them down to the Dementia unit. He stated that diet orders are inputted into the labeling system by either himself, the dietician or via a request from physical therapy. [NAME] On 03/06/18 at 2:40 pm, observations in the refrigerator on the Dementia Unit, showed that the information on the peanut butter and jelly sandwiches included the name of the resident, the date, and what the snack is. During interview with the Dietary Director and Dietitian on the unit, they both verified that the nutrition label does not state the diet type, stating that if staff are not familiar with the residents, they could pass the wrong snacks. H. On 03/06/19 at 2:52 pm, during interview the Dietary Director stated that R #81's diet change to a puree diet was not updated in the Resident Diet System (RDS) which prints out the nutrition labels for the snacks. He stated R #81 has been getting non-pureed snacks for about a year and a half. He stated that he did not know who put the order in for her pureed diet. I. On 03/06/18 at 3:27 pm, during interview the Speech Therapist stated that in (MONTH) (2017) she put R #81 on a pureed diet because of excessive chewing and pocketing of her food, not because of choking. She stated that excessive chewing could cause her to pocket her food, which could lead to aspiration. The Speech Therapist was asked if a banana was appropriate, she stated No, I don't trust her with a banana. I wouldn't clear it until I cleared it. I consider it (a banana) more regular diet. Unless it's mashed up, I wouldn't feel comfortable with her eating a whole banana. [NAME] On 03/06/18 at 3:37 pm, during interview CNA #2 stated that she believes R #81 gets a peanut butter and jelly sandwich as a snack. When asked which residents were on a pureed diet, CNA #2 did not indicate R #81 was on a pureed diet. CNA #2 stated that the snacks come from the kitchen with nutrition labels and she just hands them out to residents. CNA #2 stated that she would give R #81 a banana because she is on a regular diet. She also stated that when she passes out meals, she looks at the meal ticket and the food to make sure they match, but could not remember if R #81 was on a pureed diet. CNA #2 also stated that the bananas come from the kitchen with no nutrition labels. During the interview, CNA #2 looked at R #81's Kardex (a summary of all the resident's care needs which includes diet consistency) which showed her diet as regular/liberalized and mechanical. K. On 03/06/18 at 4:07 pm, during interview the Unit Manager stated that she just looked up R #81's diet and stated it was dysphasia pureed. She stated that on the meal tickets and CNA Kardex, it says what diet residents are on. The Unit Manager stated that as far as she knew, the snacks come from the kitchen labeled, so CNAs know who to give the snacks to. When asked if a peanut butter and jelly sandwich was appropriate, she stated, I had to clarify that too. No, it's not, unless they have been evaluated by speech therapy. The Unit Manager stated that she did not recall seeing R #81 eating a sandwich or a banana. She verified that if CNAs are passing meals with pureed food, they should see that the snacks are not appropriate. L. Record review of the Nutritional Snack Label provided by the Dietary Director dated 03/06/18, showed R #81's name, room number, and 1/2 peanut butter and jelly sandwich. M. Record review of R #81's Care Plan, revealed it was updated on 03/06/18 with the focus, goal, and interventions related to impaired swallowing. R #81 was not care planned for swallowing issues or a pureed diet prior to 03/06/18. N. Record review of the Nutritional assessment dated [DATE], revealed diet is Dysphagia puree. O. On 03/06/18 at 5:20 pm, during interview the Administrator stated that she talked to the CNA working day shift on 03/06/18 and confirmed that at around 11:00 am, she gave R #81 a whole banana and she did not mash it. Findings for R #97 P. Record review of the Physician order [REDACTED]. Q. On 03/06/18 at 3:37, during observations of the fridge on the Dementia Unit, revealed a small sealed cup of fruit chunks with R #97's name written on the top. R. On 03/06/18 at 2:19 pm, during interview with RN #1 she stated that R #97 was on a pureed diet. S. On 03/06/18 at 3:37 pm, during interview with CNA #2 she stated that R #97 was on a pureed diet. She stated that R #97 gets yogurt, soft foods or the health shake for snacks. CNA #2 did not know why the fruit cup with his name on it was in the fridge. She also stated that she has not seen him eat a sandwich or a banana. T. Record review of the 1:1 (one on one) Monitoring sheets for R #97, dated 2/16/18 to 03/06/18, revealed the following: 1. On 02/16/18 at 10:20 pm, states had a snack (banana and milk shake). 2. On 02/21/18 at 4:35 am, states he woke up and ate snack (cracker) then went back to bed asleep. 3. On 02/23/18 at 11:30 am, states still watching. Health shake, juice, sandwich. 4. On 02/23/18 at 1:12 am, states I gave him some snacks i.e. sandwich, yogurt, and shake. He went back to bed after snacking. At 5:19 am, states the resident came out of his room to the dining room, offered him some snacks, shake, sandwich and yoplait (yogurt). 5. On 02/25/18 at 7:00 am, states he's in DR (dining room) got his coffee and a cookie while waiting calmly for breakfast. 6. At 1:00 am (not dated), states resident got up, used restroom, ate a cookie went back to bed. 7. On 03/05/18 at 1:15 am, states rsd (resident) gets a cookie and milk. U. On 03/09/18 at 10:22 am, during interview the Speech Therapist stated that she was not aware that R #97 was getting non-pureed snacks. She stated I was not aware, because I would have intervened. The Speech Therapist stated that at the request of the family she evaluated R #97, and is now being monitored for a dysphagia advanced diet (mechanical soft). She confirmed that a whole banana is not appropriate on a pureed diet, stating that if the banana was mashed up it would be acceptable. The Speech Therapist stated It makes me nervous, when she said that she would expect staff to notify her if residents receive inappropriate snacks. She stated that it never occurred to her that staff who work with residents every day, that if they pass their meals why they would given them snacks that are not appropriate. She stated It's common sense to not give a resident a cookie, if they don't get one at meals, if every one else gets one with regular diets. She stated that she is going to be spending more time on the locked unit, because she didn't know staff were giving residents non-pureed snacks. Findings related to R #35: V. On 03/07/18 at 9:20 am, observation of R #35's room revealed an area on the floor between the resident's bed and the bathroom approximately 3 feet by 3 feet where several of the rectangular floor pieces were warped. The floor was slightly raised at the places where the ends of two floor pieces met creating small humps approximately half an inch in height. There were several humps across this area which made the floor an uneven surface. W. On 03/08/18 at 10:46 am, during an interview with the Maintenance Director, he stated that R #35 tends to flush items down the toilet such as wipes, towels and underwear. He stated that his toilet got clogged about 3 weeks ago and the water overflowed from the toilet and flooded part of the resident's room. He stated the wooden floor pieces were warped by the water damage which then created the uneven surface in his room. He stated he ordered new vinyl flooring and is waiting for them to arrive. X. Record review of the facility's purchase order dated 03/02/18 revealed that new vinyl flooring was ordered on [DATE]. Y. Record review of the facility's list of incidents that occurred from (MONTH) (YEAR) to (MONTH) (YEAR) revealed that R #35 had the following falls/incidents: 1. On 06/22/17 resident stated he hit his head on the bathroom door when he tried to open it. 2. On 07/03/17 resident was found sitting on the floor with no injuries. 3. On 12/24/17 resident fell trying to get into his bed while it was in the high position. 4. On 01/09/18 resident was found on the floor in his room with a bruise on his forehead. Z. Record review of R #35's most recent MDS assessment dated [DATE] revealed that his vision is moderately impaired and does not wear corrective lenses. A[NAME] On 03/08/18 at 10:45 am, during an interview with the Director of Nursing, she verified that R #35 has a history of falling but that all his previous falls occurred in his previous room. She stated that he was moved into his current room in (MONTH) (YEAR) and has not had a fall since. She stated they are planning on replacing the floor once the new floor pieces arrive. She stated she does not know the exact day as to when the flooding occurred but thinks it was a few weeks ago. The DON verified that R #35 has poor vision and that the uneven floor is a potential tripping hazard for him. |
2020-09-01 |