| 1862 |
PRUITTHEALTH-AIKEN |
425145 |
830 LAURENS STREET NORTH |
AIKEN |
SC |
29801 |
2019-12-14 |
610 |
J |
1 |
0 |
T11M11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, and review of facility policy, it was determined the facility failed to investigate an incident of potential neglect for one (1) of twenty-six (26) sampled residents, Resident #16. Resident #16 was assessed to have severe cognitive impairment and resided on the secured Memory Support Unit ([CONDITION]U). The resident was evaluated by Speech Therapy and it was determined the resident was at moderate risk for aspiration and needed a pureed diet which had initially been ordered by the physician on 3/ 6 /19. The resident's behaviors included wandering and taking resident's food from other residents in the [CONDITION]U. On 10/4/19, the resident was observed to be pale and to have difficulty breathing. When the Nurse Practitioner assessed the resident, a peanut butter sandwich was pocketed in the resident's mouth. After the sandwich was removed, the resident was suctioned, and oxygen was applied. Staff worked approximately one (1) hour to stabilize the resident. Later that evening the resident experienced respiratory distress and was transferred to the emergency room and was admitted to the hospital with [REDACTED]. The resident returned to the facility on Hospice with a [DIAGNOSES REDACTED]. The facility failed to investigate an incident potential of neglect, failed to obtain witness statements in an attempt to identify how the resident got the sandwich, thus no corrective action was taken to protect other residents from potential neglect. The facility's failure to conduct a thorough investigation of the choking incident placed residents at risk for serious injury, harm, impairment or death. The facility Administrator was notified of the Immediate Jeopardy on 12/12/19 at 1:30 PM. The Immediate Jeopardy was removed on 12/12/19 at 8:30 PM. The scope and severity was lowered to a D. The findings included: Resident #16 was admitted to the facility on [DATE] to the Memory Support Unit ([CONDITION]U). The resident's [DIAGNOSES REDACTED]. According to a quarterly Minimum Data Set (MDS) review dated [DATE] the resident's cognitive status was severely impaired, and the resident required supervision of one (1) person, physical assistance walking in room/ corridor, and required extensive one (1) person physical assistance with eating a mechanically altered diet. Review of the Care Plan with revision date 9/23/19 revealed the resident received a mechanically altered diet and would wander and eat off other resident's trays. Review of Order History Dietary Order with start date 3/6/19 end date 10/13/19: Regular, Pureed with Special Instructions: Food in bowls A Speech Therapy Plan of Care (Evaluation Only) dated [DATE]: The resident has a [DIAGNOSES REDACTED]. The evaluation determined the resident was at the moderate range for dysphagia and aspiration. The resident is on the least restrictive diet for safe po intake. Review of the facility policy, Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property with revision date of 11/21/16 revealed it is facility policy to investigate allegations and occurrences of abuse, neglect, exploitation, mistreatment and misappropriation of patient property. The administrator is responsible for assuring an accurate and timely investigation is completed. If there is an occurrence of abuse, neglect, exploitation, mistreatment or misappropriation of property an investigation will be conducted. A review of the facility policy, Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, with revision date of 11/21/16 documented it is the policy of the facility to actively preserve each patient's right to be free from abuse and neglect. Neglect is the failure of the facility to provide goods and services to a patient that are necessary to avoid physical harm, mental anguish or emotional distress. Facilities are to identify and correct and intervene it situations in which abuse, neglect, mistreatment or exploitation may occur. This should include an analysis of the following: Features of the physical environment that could make abuse, neglect, mistreatment, or exploitation more likely to occur, such as secluded areas of the facility. The deployment of staff on each shift in sufficient numbers number to meet the individual needs of patients. Monitoring of patients with needs and behaviors such entering other resident's rooms and self-injurious behaviors. Review of the Resident Progress Notes: 10/4/19 11:15 AM (Recorded as late entry on 10/6/19 at 1:32 PM) documented by Director of Health Services (DHS: Approached the unit to find the resident in respiratory distress. Nurse Practitioner (NP) and nursing staff present and providing care. The resident was suctioned, given O2 (oxygen), nebulizer treatments and antibiotics. The resident was difficult to manage, was constantly attempting to get up from chair. The resident was eventually more relaxed when standing and leaning onto staff and ambulated with staff to bed where resident was able to rest without attempts to get up. 10/4/19 7:22 PM Documentation entry by NP: Received request to come to assess the resident who was coughing. Upon arriving to the unit, the resident sitting in chair, pale and coughing. There was food pocketed in the resident's cheeks that looks like bread. A CNA (certified nursing assistant) got the food out of the resident's cheek. The resident had just eaten a peanut butter sandwich. O2 saturation checked and was [AGE]%. 02 was started at two (2) liters and was increased to four (4) liters via nasal cannula to bring 02 saturation to [AGE]%. More food was then extracted from the residents left cheek. Resident was restless taking off the 02 saturation monitor constantly wanting to sit up and stand up. [MEDICATION NAME] nebulizer was given via mask with 02 level increased to [AGE]%. Suction was started. Resident appeared to be breathing better but rales (abnormal lung sounds characterized by discontinuous clicking or rattling sounds) still heard in bilateral lungs, A stat chest x-ray was ordered and [MEDICATION NAME] (antibiotic) one (1) gram was given IM (intramuscular) by the nurse. Resident then ambulated to room with 02 saturation still low at 82%. 02 at two (2) liters with concentrator was increased to three (3) liters per minute with 02 saturation at [AGE]-94%. Resident remained stable and rested well. 10/6/19 5:38 PM Documentation entry by RN (Registered Nurse) #1: (Recorded as a late entry): On 10/4/19 around 10:46 PM Resident #16 was noted to be pale with cool clammy skin and was attempting to cough. The resident's 02 saturation of [AGE]% and was given scheduled [MEDICATION NAME] nebulizer treatment with 02 saturation increased to 78% but decreased to [AGE]-[AGE]% when resident began moving around. The NP on call notified and received orders to send to hospital. An interview was conducted with the Administrator on [DATE] at 3:25 PM. The Administrator stated nobody knows how Resident #16 got the peanut butter sandwich he/she choked on. The nurse on the unit said she didn't know how the resident got the sandwich. She further said no investigation was conducted on Resident #16's choking incident but concluded the Director of Health Services (DHS) or a nurse could have done the investigation. An interview with the DHS on [DATE] at 2:00 PM revealed Resident #16 would not sit down for staff and the resident would remove food from other resident's meal trays. He/she said staff on the Memory Support Unit ([CONDITION]U) are constantly watching the residents and there was not a whole lot more staff could do, all staff could do was intervene as needed. The DHS stated she did not know how the resident got the sandwich, I did not address it at the time. He/she said I just asked nurses and CNA's (certified nursing assistants) and they said they didn't give the sandwich to the residents. The DHS concluded he/she did not initiate an investigation into Resident #16's choking incident. A further interview with the Administrator on 12/12//19 at 1:15 PM revealed he/she would not do an investigation just because a resident got the wrong tray or ate a food item that was not part of the resident's diet. The facility's failure to conduct a timely through investigation to the choking incident of Resident #16 in an attempt to identify causative factors of the incidents placed residents of the facility at risk for serious injury, harm, impairment or death. REMOVAL PLAN: Facility failed to remove finger food intervention for a resident on a puree-only diet. [AGE] year-old resident on the secured dementia unit who staff identified as constant wanderer, required feeding by staff, and had a behavior of taking food from other residents' trays. This occurred on or around 10/4/2019. Resident no longer resides in the facility. All residents on the [CONDITION]U with a mechanically altered diet have the potential to be affected by the alleged deficient practice. All [CONDITION]U resident diets were reviewed to identify those with mechanically altered diet by the Case Mix Directors. These care plans have been reviewed and updated to ensure that interventions are appropriate for all [CONDITION]U residents with mechanically altered diets. The team reviewed 15 residents with mechanically altered diets and did not need to make any revisions. The care plan policy was last reviewed on 12/12/19 by the interdisciplinary team and signatures were secured. No nursing staff shall work until they have completed in services on updating care plans starting 12/12/19. Newly hired staff will be in serviced on updating care plans during orientation and annually thereafter by the CCC. Staff will not be permitted to work until education has been completed. The Director of Health Services (DHS), and/or nursing unit managers will review [CONDITION]U residents care plans weekly to ensure that they have been updated with acute changes, for four weeks starting 12/12/19 and quarterly there after for three months. The Director of Health Services (DHS) and or Unit Manager will report any adverse findings to the Administrator immediately and to QAPI. The Director of Health Services (DHS) and/or Unit Manages will review the Facility Activity Report five times a week to monitor for any acute changes of condition including diet changes and updated care plan for four weeks. The Director of Health Services (DHS) and/or Unit Managers will review care plans to ensure care plan interventions are updated. Any adverse findings will be reported by the Director of Health Services (DHS), Assistant Director of Health. An Ad Hoc QAPI meeting was held with the Medical Director, the Administrator, Director of Health Services (DHS), Licensed Practical Nurse, Restorative Nurse and Certified Nursing Assistant on 1212/2019 to discuss the immediate jeopardy finding and the removal plan. All corrective actions were completed by 12/12/2019. The immediacy of the IJ was removed on 12/12/2019. |
2020-09-01 |