cms_SC: 60
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 60 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2017-06-14 | 223 | J | 1 | 1 | J20Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews, the facility failed to provide needed services to 1 of 3 residents reviewed for change in condition. Resident #48 had a change in condition that required respiratory assessment and treatment which the resident did not receive. In addition, based on observation, record review and interview the facility failed to ensure all residents with concerns with positioning for safe meal intake to avoid choking were given adequate assistance in set up at meal time. Three of 18 residents (Residents #6, #22 and #49) noted to have positioning concerns were found to be improperly positioned in bed to feed themselves effectively and safely. The Certified Nursing Assistant caring for Residents #22 and #49 residents had just been inserviced on how to provide assistance to residents with positioning for meal intake to ensure safety. The findings included: The facility admitted resident # 48 with [DIAGNOSES REDACTED]. Review of Nurses' Notes from [DATE] through [DATE] revealed resident was total care for all Activities of Daily Living (ADL's). S/He was in a persistent vegetative state. On [DATE] at 9:30 AM: resident lying in bed with eyes open, when breathes makes a gargling sound. resp even/unlabored. will continue monitoring. 10:20 AM called to room per Certified Nursing Assistant (CNA). Resident lying in bed with Head of bed (HOB) elevated ( ^) noted to have beige secretions coming out of mouth. No respirations noted. Code blue called &Cardiopulmonary Resuscitation (CPR) was initiated, no pulse, 911 called 10:30 AM Emergency Medical Services (EMS) here. took over CPR. To hospital via stretcher. Per Physician's Cumulative Orders for ,[DATE]-[DATE] an order for [REDACTED]. On [DATE] at 3:30 PM CNA # 44 was interviewed by the surveyor. The CNA had reported to the nurse the change in condition of the resident. In the morning s/he was coughing funny, making a strange noise. I told the nurse s/he needed to check on the resident, s/he was making a strange noise and needed to be suctioned. That was the first time. Don't remember the exact time. Somewhere between 7:30 and 8:00 AM. 2nd time the original aide heard her/him and went and told the nurse, s/he needed to check on the resident. I was standing there. We were getting the residents ready to eat. S/he (nurse) was standing outside the room, passing medicine. S/he heard us talking about telling her/him to come and check the resident. S/he came in the room and looked at him/her (resident). S/he said, 'yeah s/he do need to be suctioned. Around 10:30 the CNA (assigned to the resident) called me to come and look. S/he said s/he thought the resident was dead. I went into the room. His eyes was open and he had foam out is mouth. I called her/his name, I rubbed her/his chest, nothing. I ran up to the desk where the nurse was at. I yelled are you calling a code blue? S/he said she was about to. We tried to tell her that he was having a hard time breathing. We take care of these people every day. We know when something ain't right. On [DATE] at 8:30 AM, Registered Nurse (RN) #138 was interviewed via phone by surveyor. The RN stated the resident was gurgling during med pass. I went and found a suction machine, but it did not work. I never got a suction machine to work. The RN stated s/he had removed the suction machine from the crash cart. I think there are 3 crash carts. It was about 9:00 AM I can't remember exactly. I never had to suction her/him before. At 2:50 PM: CNA # 47 was interviewed by the surveyor. When I came in (,[DATE]), when I went to his room CNA # 44 was already in there. S/He (the resident) was making a noise like something was in her/his throat. CNA # 44 said s/he had already talked to the nurse. The nurse was outside the door with her/his med cart and said ok. Then the trays came out about 8:30 AM. The CNA and I were feeding two other residents (4 residents were in that room) and resident #48 was making noise again. I go and talked to the nurse and told her/him the resident needed to be suctioned. The nurse was a RN, I don't remember her/his name. I am prn (as needed). That time s/he came in and said, 'OK, I will suction her/him. When s/he (the nurse) came in s/he just looked at her/him (the resident). It was 10:00 something when I went and looked at her/him and s/he wasn't breathing. The other CNA was walking by and I called her/him in. The other CNA was in the room. I went to the desk and told the nurse to come and look, I didn't think s/he was breathing. S/he walked down to the room and looked at him. Again, didn't do anything. S/he left the room and got her/his chart. We asked her/him if s/he was going to call a code. S/he called the code and everyone came rushing into the room. They sent me to escort the ambulance. So I went outside and brought them in. The other CNA usually worked with the resident. Review of the facility investigation revealed the facility had obtained statements from the two Certified Nursing Assistants. There was no statement from the Registered Nurse. Review of the facility's summary of the investigation revealed, RN #138 stated when s/he entered the room the resident was unresponsive and s/he immediately reported to the nurse's station to call a code. She did not check vitals or pulse. S/he also stated s/he previously went into the room at 0900 and the resident sounded gargly but respirations were even and unlabored, there was no suction machine in the room at this time. The nurse was asked why s/he didn't suction in a timely manner and s/he stated that s/he could not find a suction machine on the crash carts. Other staff members were interviewed and it was determined that there were suction machines on each crash cart. The crash carts were located at each nurses station. During the survey, the crash carts were observed on ,[DATE], ,[DATE] and on [DATE]. Each observation the crash carts contained a suction machine as well as suction cannisters, suction tubing and suction catheters. On each crash cart was a check list which had been checked daily for required equipment. Record review for Resident #6 of physician progress notes [REDACTED].diabetes with peripheral circulatory disorders, type 1 .coronary [MEDICAL CONDITION] (hardening/narrowing of arteries) of unspecified type of vessel . On [DATE] at 12:57 PM Resident #6 was observed sitting very low in her bed, with the head of the bed raised causing her to to have her chin to her chest. Her tray of food was on the table and she was feeding herself. When asked if she is comfortable like that, she confirmed that she was not. On [DATE] at 12:37 PM during an observation, she is slouched in her bed, not at a 90 degree angle and tilted on her right side, and is feeding herself. A Certified Nurses Assistant (CNA) Staff #34 is currently in the room feeding another resident. The same CNA brought her food. Her call light is out of reach hanging on the other side of her bed. On [DATE] at 12:37 PM During an interview with the Resident #6, when asked if she still works with therapy, she stated that she does, when asked if she remembers what they tell her when she eats, she stated, yes, they tell me I am supposed to be sitting straight up so the food goes down into my stomach, not like this. On [DATE] 12:45 PM R#6 began yelling at Certified Nurse's Assistant (CNA) Staff #34, asking several times to put her head up, and CNA Staff #34 continued saying that the bed was all the way up. R#6 asks two more times, and CNA Staff #34 stated that her head is fine. CNA Staff #34 came to the edge of the bed and adjusted her tray, but did not put her head up or help her adjust in the bed. The resident remained in the same position, slouched and turned to the right side of the bed. On [DATE] at 12:47 PM during an interview with Resident #6, when asked if she is having trouble swallowing that way, she states,yes, everything is hard sitting like this. Resident #6 begins coughing, and coughed up coleslaw that she was eating. LPN (Licensed Practical Nurse) Staff #12 and LPN Staff #38 were in hall and were asked to come straighten up the resident and check on her. They came in and pulled her up in bed and repositioned her, but not in a 90 degree angle. She remained low in the bed and tilted to the right side. On [DATE] at 12:57 PM, during an interview with R#6, when asked if they always put her head up to eat, she stated no. She stated, this is better than when I am laying down, I cant eat like that. All residents were observed for proper positioning while in the bed feeding them self. During the extended survey observation was made of resident #22 on [DATE] at 5:15 PM and revealed she was observed to be served her meal and the nursing assistant elevated the head of her bed but she did not pull the resident up in the bed. Resident #22 remained slouched down in the bed and was in poor position to feed herself when her meal was served. The staff prepared her meal and left her to feed herself while she was still not positioned straight up in the bed as she was still noted to be slouched down in the bed. Resident #22 was observed to feed herself but was noted to struggle getting the food on her spoon and feeding herself without spilling the food on herself. During this observation the Social Service staff #108 walked by the room and observed Resident #22 in her bed positioned poorly and she entered the room and ask the resident why are you laying so far back in the bed trying to feed yourself. She began to reposition the resident and when doing so the resident began to cough/choke on the food that she had in her mouth. The Social Service staff #108 attempted to assist the resident by offering her a drink of water but the resident continued to cough and her eyes began to water and she was not able to speak. The Social Service staff #108 called for the nurse to come the the room and the nurse assessed Resident #22 and she was then able to drink water and she ceased coughing. Nurse #51 and Social Service Staff #108 pulled the resident up in bed and repositioned her in an adequate position so she could feed herself in an upright position and the resident was then able to feed herself her meal with no further concerns. Record review revealed Resident # 22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Minimum (MDS) data set [DATE] revealed she had no swallowing disorder and receives a therapeutic mechanically altered diet. She was noted to require the extensive assistance of two staff members to position her in bed, required eating supervision with oversight and encouragement/cueing and was a set up only with her meals. Review of Resident #22's current care plan dated [DATE] revealed interventions to include that staff are to assist her with eating, monitor for mastication difficulties, monitor her intake for safe swallowing and report any problems to the nurse. Review of Nurse Aide flow records for (MONTH) and (MONTH) (YEAR) revealed she requires the extensive assistance from staff to turn in bed. Her record was silent to any speech therapy orders or evaluations. During this same meal observation on [DATE] at 5:15 PM Resident #49 was also observed during the supper meal service. He was observed to be served his meal and nursing assistant #93 elevated the head of his bed but she did not pull the resident up in the bed to position him properly so he could feed himself safely. Resident #49 remained slouched down in the bed and he was leaning the to left against the bed rail. The Nurse Aide Staff #93 prepared his meal and left him to feed himself while he was not positioned straight up in the bed so he could eat without risk of choking and potential aspiration. The Social Service staff #108 walked by Resident 49's room and observed him slouched down in the bed, leaning to the left and attempting to feed himself. She repositioned the resident by pulling him up and over in the bed and placing pillows beside him for positioning so he could feed him self without risk of choking. When the Social Service Staff #108 repositioned him so he could feed himself safely he was not able to self assist with positioning. Interview with Nurse Aide #93 on [DATE] at 5:30 PM revealed she had been educated by the Speech Therapist when she arrived on shift on this date prior to the evening meal about how to properly position resident while they are eating in bed. She said she was in-serviced to elevate the head of the bed and to use pillows as needed to position the resident so they were in a safe position to feed them self. She stated she had never observed Resident #22 or #49 to have any issues feeding themselves in bed and had never observed them to choke. Review of the sign in sheet for the education/in-service provided by the Speech Therapist on [DATE] revealed Nurse Assistant #93 was present for the mandatory in-service on safe positioning of resident while eating. Review of the education that was provided to the staff during this mandatory in-service revealed they were educated on assisting residents with feeding and positioning, swallowing precautions and a review was done of swallowing guidelines for the patient and the caregiver. This in-service was to be provided to all staff on shift on [DATE] and to all staff who worked on the days following prior to them providing care until all the staff who assisted residents with meals had been in-serviced. The Corporate Nurse #134 was advised of the observation of Resident #22 being poorly positioned by Nurse Aide Staff #93 on [DATE] at 6 PM. At 6:10 PM she advised this surveyor that she had spoken with Nurse Aide #93 and the Nurse Aide had been suspended due to the poor positioning of Resident #22 during her meal after she had just been inserviced on how to properly position resident for safe eating while in bed. The corporate Nurse #134 verified Resident #22 had not had any previous speech evaluations and had not had any incidence of previous choking or coughing incidents while feeding herself. The staff failed to monitor Resident #22 for safe swallowing per her nutrition care plan and failed to position her in a safe manner in bed so she could eat her meal on [DATE] at 5:30 PM. The staff also failed to position Resident #49 in a position while in bed to promote safety while he was feeding himself in bed. Both residents were found by the Social Service Staff #108 to be poorly positioned and Resident #22 was observed to experience a coughing/choking episode while feeding herself in bed while being poorly positioned. Two additional residents were observed during the meal service on [DATE] as they were identified by the facility as being on swallowing precautions. At 5:05 PM Resident #1 who was identified by the facility as being on swallowing precautions was observed sitting in a wheelchair in the dining room feeding himself. He was observed eating a pureed diet and thick liquids and was observed to have no concerns while feeding himself. Resident #20 was also observed in the dining room in her wheelchair feeding herself and no concerns were noted as she fed herself a mechanical soft diet with chopped meats. On [DATE] at 2:10 PM, Corporate Nurse Staff #134, Regulation Specialist Staff #135, and Director of Nursing Staff #136 were notified that Immediate Jeopardy (IJ) began on [DATE] at 12:47 PM when Resident #6 was observed lying slouched down in her bed on her right side and began choking while feeding herself lunch after repeated requests from the resident to be placed in a position so she could feed herself safely. On [DATE] the Administrator was advised of a second Immediate Jeopardy that began on [DATE] when a resident had a change in condition related to respiratory issues that was not addressed by the nurse. The resident became unresponsive and was transported out of the facility to the hospital and expired. The facility's Allegation of Compliance (A[NAME]) to address the concerns with positioning of residents to prevent episodes of choking was received on [DATE] at 6:22 PM. The A[NAME] included: 1. Affected resident has been assessed by Speech Therapy and staff educated on proper positioning during meals. 2. Education provided to floor staff regarding proper positioning of residents who eat in bed by speech therapy and nursing management prior to dinner meal on [DATE]. 3. DON (Director of Nursing) or designee to visually check on residents during meal times to ensure proper positioning in bed at each meal x 7 days. 4. Speech Therapy will screen residents noted to have any difficulties with swallowing as reported by nursing on therapy referral form. 5. Residents noted for speech therapy screen will be reviewed in Q[NAME] (Quality of Care) meeting weekly beginning immediately. 6. Speech therapy to provide DON with copy of recommendations for processing to current orders or Kardex. 7. Staff that did not attend initial education on [DATE] will be educated on proper positioning and aspiration precautions before working the floor. The facility's Allegation of Compliance (A[NAME]) to address failure to assess and treat respiratory issues was submitted [DATE] to the surveyor and included the following: 1) Affected resident was transported to the hospital via 911 for evaluation and expired at the hospital. 2) Allegation of neglect was reported to the State Agency as required. 3) RN involved was suspended, terminated and reported to the SC Board of Nursing. 4) DON and Unit Managers to provide education on [DATE] to all nurses and Certified Nursing Assistants on neglect, oral suctioning procedure, location of suctioning equipment, recognizing change in condition and performing respiratory assessment. Inservice is mandatory and no one will be allowed to work until education is completed. 5) All resident's orders were audited by Nurse Management staff for identification of orders for advanced respiratory care/oxygen/suction. Findings were 2 residents in house with orders for continuous oxygen, 2 residents in house with orders for PRN (as necessary) oxygen and no residents in house with suction orders. 6) All respiratory care plans for affected residents have been reviewed and revised if needed on [DATE]. 7) Residents that have the potential for advanced respiratory care have been re-assessed for the need for suction on [DATE]. 8) Maintenance Director and Nursing verified that all 8 suction machines in the facility were functioning properly and central supply clerk verified that suction supplies are readily available on [DATE]. 9) A root cause analysis determined the nurse failed to respond to a change in condition of a resident and failed to respond appropriately to assess and treat. Equipment was available and functioning at the time of the incident. All staff including any new hires have been re-educated on neglect, respiratory assessment, equipment to use and location of equipment and recognizing change in condition. 10) The designated staff and DON will verify location of suction machines daily and nurses will check weekly their functionality. 11) This A[NAME] has been reviewed in an ad hoc QAPI meeting with the Medical Director's involvement and will be reviewed monthly at the QAPI meetings. The survey team completed record review, observation and interview to ensure the facility had implemented their A[NAME]. The Immediate Jeopardy at F279, F323 and F520 was removed on [DATE], but the citations remained at a lowered scope and severity of D. The Immediate Jeopardy citations at F223, F281 and F328 were removed on [DATE] after observations and interviews were completed to ensure the A[NAME] was in place and in practice. These citations remained cited at a lower scope and severity of D. | 2020-09-01 |