| 1863 |
PRUITTHEALTH-AIKEN |
425145 |
830 LAURENS STREET NORTH |
AIKEN |
SC |
29801 |
2019-12-14 |
657 |
J |
1 |
0 |
T11M11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, and review of facility policy, the facility failed to revised a care plan for one 1 of 26 sampled residents, Resident #16. Resident #16's initial care plan dated 6/5/18, for wandering behavior listed interventions which included giving the resident finger foods. The resident's diet order was changed on 3/3/19 to pureed diet due to swallowing difficulty. Staff failed to revise the resident's care plan which placed the resident at risk for harm and on 10/4/19 the resident choked on a peanut butter sandwich and was transferred to the emergency room later in the day and diagnosed with [REDACTED]. The facility's failure to update Resident #16's Care plan placed the resident 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 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] with [DIAGNOSES REDACTED]. Review of the facility policy, Care Plans, with revision date 10/5/17 revealed it is the policy of the facility to have a comprehensive care plan with the focus of the resident at the center of control. The care plan must include at a minimum information necessary to address the resident's health and safety concerns to prevent decline or injury. Care plans will be updated by nurses, Case Mix Director (CMD), or any member of the interdisciplinary team so that the care will reflect the resident's needs at any given time. The resident's quarterly Minimum Data Set ((MDS) dated [DATE] noted the resident was assessed with [REDACTED]. According to the assessment, the resident required extensive one (1) person physical assistance for transfers, dressing, eating, toilet use, personal hygiene and was totally dependent on one (1) staff for bathing. The resident had no impairment for functional limitation in range of motion for upper and lower extremity. The resident received a mechanically altered diet and speech therapy services were provided on [DATE]. Review of the Care Plan with revision date 9/23/19: Problem [ENTITY]t Date 6/5/18: 1.Category: Nutritional Status: Resident receives a therapeutic mechanically altered diet and is edentulous. History of significant weight loss with poor appetite Long Term Goal: Maintain weight without significant weight loss (Target date [DATE]) Approach [ENTITY]t Date:1/31/19: Pudding added to all meals, Observe and record all po (by mouth) intake. Provide diet as ordered. Provide alternative meals when resident is uninterested in meal served. Provide supplements as ordered. Weekly weight. 2. Problem [ENTITY]t Date 6/5/18: Category: Behavioral Symptoms: Resident wanders daily. Refuses to rest. Leans to one (1) side when tired. Will go in other's rooms. Will eat off other resident's trays. Refuses care, can be verbally and physically aggressive. Long Term Goal: Will wander safely within specified boundaries. Will have decreased episodes of refusing care and aggression. (Target date [DATE]) Approach [ENTITY]t Date: 8/26/19: Maintain a calm environment. Offer finger foods (initiated 6/5/18). Provide diversional activities. Remove resident from unsafe situations-other resident rooms, Staff to intervene to protect the right and safety of others. 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 is total care for ADL's (Activities of Daily Living), wanders the halls constantly. The resident has a [DIAGNOSES REDACTED]. The resident was administered the MASA ([MEDICATION NAME] of Swallowing Ability) to assess swallow functions with resident scoring 143, placing the resident in the moderate range for dysphagia and aspiration. The resident is on the least restrictive diet for safe po intake. Review of the Resident Progress Notes between [DATE] through 10/3/19 revealed the resident had 13 incidents of the resident wandering the halls incessantly, in other's room and not wanting to take rest breaks. An entry on 9/15/19 at 6:59 PM Resident continues to wander on [CONDITION]U and the only activities he/she is truly interested in is meals and snacks and on 10/2/19 at 6:37 PM resident was seen by staff to pick up food with his/her hands and threw it at another resident in dining room. Resident was removed from the dining room and redirected. Further review of the Resident Progress Notes: 10/4/19 at 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 were present and providing care. Staff suctioned the resident applied O2 and a nebulizer treatment (medication used to open airway passages) was administered. The resident was difficult to manage as was making constant attempts to get up from chair. When the resident oxygen saturation levels improved to 90-[AGE]% the resident was transferred to room with staff assistance. 10/4/19 7:22 PM Documentation entry by NP (Nurse Practitioner): Was asked to come and look at the resident who was coughing. The resident is in a chair appearing pale and coughing. There is food pocketed in 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. More food was extracted from the residents left cheek. O2, nebulizer treatments and antibiotics were administered to the resident. Resident ambulated to room with staff assistance and 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 sitting in a chair in common area of [CONDITION]U. Resident was pale and attempting to cough. The resident's skin was cool and clammy with 02 saturation of [AGE]%. Resident given scheduled [MEDICATION NAME] nebulizer treatment with 02 saturation increase to 78% but decreased to [AGE]-[AGE]% when resident began moving around. Bilateral rales in lungs. Resident took off 02 and began hitting nurse. NP on call notified and received orders to send to hospital for evaluation. E[CONDITION] arrived and resident left facility via stretcher. An interview with LPN #1 on 12/13/19 at 1:10 PM revealed all nurses are responsible for updating care plans when physician orders change or if there is a change in the resident's condition. LPN#1 said if an order is received to change the resident's diet the nurse should take the order off, send a copy to dietary and update the care plan immediately. Unit Manager (UM) #1 said during an interview on 12/13/19 at 1:20 PM care plans should be updated for every new physician order or whenever there is a change in resident condition. The UM stated all nurses are educated on updating care plans and should be ensuring care plans are updated prior to leaving their shift and she could not say why Resident #16's care plan had not been revised to remove finger foods from the care plan. An interview with the Director of Nursing (DON) was conducted on 12/13/19 at 1:30 PM The DON stated nurses should update care plans at the time of change of condition with new interventions as needed and when new orders are received. The facility's failure to update Resident #16's Care Plan placed the resident 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 |