cms_UT: 4
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4 | HERITAGE PARK HEALTHCARE AND REHABILITATION | 465003 | 2700 WEST 5600 SOUTH | ROY | UT | 84067 | 2018-01-17 | 684 | D | 0 | 1 | 1JS611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined that the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, residents were observed to be coughing during meals and were not assessed for swallowing difficulties. In addition, a resident with a physicians order for thickened liquids was observed to receive regular liquids. Resident identifiers: 65 and 66. Findings include: 1. Resident 66 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/11/18 at 12:28 PM, an observation was made of resident 66 in the Secure Needs Unit (SNU) dining room. Resident 66 was observed to be coughing. Resident 66 was observed to be served thin liquid beverages. Resident 66 was observed to cough when she drank the beverages. Resident 66's medical record was reviewed on 1/11/18. A nutrition care plan dated 9/6/17 and updated 1/5/18 revealed, (Resident 66) has nutritional problems or potential nutritional problems r/t (related to) edentulous, requires mechanically altered diet. One of the goals developed was, Tolerate diet texture. An intervention developed was, Monitor/document/report to MD (medical doctor) prn (as needed) for s/sx (signs and symptoms) of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals. Resident 66's progress notes revealed the following entries: a. 1/2/18 at 1:57 PM, Res (resident) currently showing s/sx of influenza. MD notified. Obtain influenza A and B culture. b. 1/2/18 at 2:23 PM, .MD notified of lab results. No new orders at this time. c. 1/3/18 at 6:00 AM, Result received for flu swab on 1/2, negative for Influenza at this time. MD notified. [MEDICATION NAME] ordered for all. d. 1/5/18 at 2:27 PM, Registered Dietitian Note .Resident with flu s/s n (nausea)/v (vomiting), fever lab negative influenza. Meal intake poor (less than) 50% s/s flu effecting intake. FORTIFIED MECHANICAL SOFT texture, THIN LIQUIDS consistency, decaf coffee, may use sippy cups to drink liquids for resident comfort. e. 1/6/18 at 11:58 PM, Resident continues on [MEDICATION NAME]. no s/sx adverse effects. coughing continues. On 1/11/18 at approximately 2:00 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that there were no residents with symptoms of the flu in the SNU. The DON stated that she talked with the Speech Language Pathologist (SLP) and the SLP did not have concerns about residents coughing during the meal on 1/11/18. On 1/17/18 at 11:15 AM, an interview was conducted with the facility SLP. The SLP stated that on 1/11/18 the DON talked to her about resident 66 coughing during meals. The SLP stated that nursing staff informed her on 1/12/18 that resident 66 was coughing and liquid was slipping out of her lips. The SLP stated that she assessed resident 66 and determined resident 66 required nectar thickened liquids. The SLP stated that resident 66 refused, so a risk verses benefits form was signed by resident 66. The form titled Risks/Benefits Notification was signed on 1/12/18 by resident 66 after the observation of resident coughing with beverages in the dining room. 2. Resident 65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/10/18, the breakfast meal service was observed on the SNU. Resident 65 was served her breakfast at 8:00 AM. Resident 65 was served a mechanical soft diet with thin liquids. Resident 65 coughed through out the meal service including after drinking fluids and after bites of food. On 1/11/18, resident 65 was observed during the noon meal service on the SNU. Resident 65 coughed multiple times and stated to the SLP. Resident 65 stated the the SLP, I choked on something that I ate. The SLP removed resident 65's thin liquids and provided resident 65 with nectar thick liquids. Resident 65's medical record was reviewed on 1/11/18. On 12/1/17 a nutritional care plan was developed for resident 65. The facility staff documented a focus area of, .has nutritional problem or potential nutritional problem r/t (related to) Dementia with lewy bodies, [MEDICAL CONDITION], anxiety disorder, DM (diabetes mellitus) (type) II, Stage 3 [MEDICAL CONDITIONS](hypertension), [MEDICAL CONDITION], (and) mood disorder. The goal developed was, Will maintain adequate nutritional status as evidenced by maintaining weight with no s/sx of malnutrition through review date. One of the interventions developed to achieve the goal was, Monitor/document/report to MD PRN for s/sx of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals. An interview was conducted with Certified Nurse Assistant (CNA) 6 on 1/11/18 at approximately 8:15 AM. CNA 6 was asked if she reported that resident 65 was coughing throughout the meal service on 1/10/18. CNA 6 stated that she did not report that resident 65 was coughing. An interview was conducted with Licensed Practical Nurse (LPN) 3 on 1/11/8 at approximately 8:20 AM. LPN 3 was asked if she received a report of resident 65 coughing through out the meal service on 1/10/18. LPN 3 stated that she had not received a report of resident 65 coughing during the meal service. On 1/11/18, the SLP completed an swallowing evaluation on resident 65. The SLP document that resident 63 had dysphagia during the oral phase and dysphagia during the oropharyngeal phase. On 1/16/18 at 8:05 AM, resident 65 was observed during the breakfast meal service. Resident 65 was served a glass of milk and a glass of water that had not been thickened. An interview was conducted with CNA 3 on 1/16/18 at 8:10 AM related to resident 65's thin liquids. CNA 3 stated that resident 65 was not on thickened liquids. An interview was conducted with LPN 1 on 1/16/18 at 8:13 AM related to resident 65's thin liquids. LPN 1 stated that resident 65 was to be served nectar thickened liquids. An interview was conducted with CNA 4 on 1/16/18 at 8:15 AM. CNA 4 had a glass of water and a glass of milk in her right hand that was covered with a burgundy napkin. When questioned, CNA 4 stated that she had removed the thin liquids that she had served to resident 65. CNA 4 stated that she did not know that resident 65 was to receive nectar thickened liquids. An interview was conducted with the DON on 1/16/18 at 8:30 AM, The DON stated that staff assisting in the dining rooms were to report episodes of coughing during the meals to the charge nurse. | 2020-09-01 |