| 4137 |
MT PLEASANT HEALTHCARE AND REHABILITATION |
445374 |
904 HIDDEN ACRES DR |
MOUNT PLEASANT |
TN |
38474 |
2016-11-03 |
154 |
J |
1 |
0 |
J51L11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to inform the responsible party/Power of Attorney of a change in the treatment when a 60 cubic centimeter syringe was used to force feed food and liquid for 1 resident (#1) of 6 residents who were totally dependent on staff for eating. This failure placed all residents at risk for aspiration and requiring total dependence on staff for eating in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death of a resident). The Administrator, Director of Nursing and the Quality Assurance Nurse were informed of the Immediate Jeopardy on [DATE] at 3:00 PM in the Administrator's office. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician telephone Orders revealed an order on [DATE] for a pureed (blenderized food) diet. Continued medical record review revealed no physician orders from admission to discharge, to syringe feed Resident #1. Medical record review of the Speech Therapy Evaluation and Plan of Treatment dated [DATE] revealed Resident #1's diet was changed to pureed due to pocketing (food getting stuck in mouth), increased feeding time and lethargy. Further review revealed Resident #1 had used general swallowing techniques/precautions and upright posture during meals 70% (percent) of the time by [DATE], was tolerating the pureed diet while fed by staff, caregiver/staff were educated on safe swallowing strategies including bite/sip, small bites, and positioning. The swallowing treatment training included small bites/sips (,[DATE] to ,[DATE] teaspoon) and facilitation of body positioning to increase safety with intake. Medical record review of the Progress Notes revealed the following: [DATE] at 11:30 PM .No further emesis noted, had earlier after lunch x (times) 1. Afebrile . [DATE] at 2:15 PM .Moderately large emesis noted during activity in dining room. Afebrile . [DATE] at .1:30 PM Res (resident) consumed 100% of meal with asst (assist) with no dysphagia (difficulty swallowing). Res vomited very large amt (amount) of liquid et (and) pureed food. Res entered Cheyne-Stokes (abnormal pattern of breathing characterized by progressively deeper and sometimes faster breathing, followed by a gradual decrease that results in a temporary stop in breathing) respirations et was unresponsive. Nurse at this x (time) went to supply closet to obtain suction equipment .at 1:34 PM Re-entered room. Noted absence of pulse, B/P (blood pressure) et respirations. Skin pale/gray et cool to touch. RN (Registered Nurse) #1 Supervisor notified .at 1:40 PM Pronounced deceased . Interviews with Licensed Practical Nurse (LPN) #5 on [DATE] at 2:55 PM and at 4:25 PM on the long hall and the conference room, on [DATE] at 11:10 AM in the conference room, on [DATE] at 4:10 PM in the conference room, and on [DATE] at 8:30 AM on the long hall revealed Resident #1 had been pocketing food and had ,[DATE] vomiting episodes after eating. Further interview revealed the LPN had .fed (Resident #1) Magic Cup (nutritional supplement) and fluids ,[DATE] times by syringe .a couple of months before hospice started .I gave Magic Cup and water by syringe the morning of [DATE] . and (Resident #1) .wanted water and could no longer suck on a straw .I didn't want him dehydrated . When asked why the LPN used the syringe, the LPN stated .I was trying to help the man out . When asked what happened to the syringe the LPN stated .I told Certified Nurse Aide (CNA) #4 to throw it away because there was no doctor's order for it . When asked when you saw CNA #4 spoon feeding the resident lunch and you told CNA #4 the syringe was available for use you knew there was a possibility the CNA would use it, would you consider that force feeding, the LPN stated I guess I would. Continued interview, when asked if the LPN had informed Hospice, her supervisors, the physician, the resident or responsible party/Power of Attorney of the use of the syringe prior to Resident #1's death, the LPN stated No. Further interview revealed, when asked since the resident did not want artificial feeding and you used a syringe to force food and fluid into his mouth, do you think you violated his right to make the decision in the change of the method of being fed, the LPN stated .it was against his wishes .I took away his autonomy . Interviews with CNA #4 on [DATE] at 9:25 AM and [DATE] at 10:15 AM and 12:35 PM, in the conference room and the nursing station revealed CNA #4 had been spoon feeding Resident #1 lunch on [DATE] when LPN #5 entered the resident's room and informed the CNA .syringe in drawer and she told me to try to use it. I got syringe out, liquefied the pureed food with the fluid on the tray and put a little in his mouth, he swallowed .he ate all the food, 100% and when I was done feeding he started vomiting . When asked when she was spoon feeding the resident lunch how had the resident been accepting the by mouth food, the CNA stated .he wasn't taking it like before . When asked why she used the syringe, CNA #4 stated .(LPN #5) told her the LPN had been using the syringe throughout the day with magic cup and juice and he did fine . When asked what happened to the syringe, CNA #4 stated .(CNA #1) told her that (LPN #5) told (CNA #1) to tell (CNA #4) to get the syringe out of there, I threw it in the trash in the resident's room, and then I removed it and took it to the hopper room trash . Telephone interviews with the Hospice Patient Care Coordinator on [DATE] at 8:45 AM and 10:00 AM, and on [DATE] at 10:30 AM, when asked regarding the resident's POST status and having a syringe used to force food into the mouth how that would affect resident's rights stated .syringe is force feeding . Interviews with the Speech Therapist on [DATE] at 11:10 AM and on [DATE] at 8:40 AM, in the therapist office and the conference room revealed Resident #1's pureed diet was primarily due to pocketing, increased time feeding and lethargy. Further interview revealed .he was definitely an aspiration risk when I changed the diet to pureed (on [DATE]) due to lethargy and there are no circumstances you should use a syringe .such a high risk for everything to go wrong and my biggest fear was for aspiration . Interviews with the Director of Nursing (DON) on [DATE] at 3:40 PM, [DATE] at 10:50 AM and 4:40 PM, [DATE] at 12:53 PM, and [DATE] at 8:35 AM and 1:45 PM. Further interview revealed the DON was not aware a syringe was being used to feed a resident prior to the event. The DON stated she had been notified by RN #1 of Resident #1's death on [DATE] and of being fed lunch with a syringe, vomiting and then the death after the resident was pronounced and had left the building. |
2019-11-01 |