cms_WV: 11317
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 11317 | LAKIN HOSPITAL - STATE | 5.1e+125 | 1 BATEMAN CIRCLE | WEST COLUMBIA | WV | 25287 | 2011-01-12 | 323 | G | 1 | 0 | 630F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to provide adequate supervision to prevent an avoidable accident to one (1) of four (4) residents reviewed for swallowing problems. During the evening meal on 12/02/10, dietary staff provided for Resident #83 a mechanically altered meal contrary to his physician order [REDACTED]. Prior to the on-site investigation into this choking incident by the State survey and certification agency, the facility took prompt actions to identify and correct system failures that permitted dietary staff to send the wrong tray to a resident and that allowed the nursing staff to serve the wrong diet, to ensure this type of avoidable accident did not recur. Resident identifier: #83. Facility census: 90. Findings include: a) Resident #83 Review of facility records revealed Resident #83 suffered a choking episode during the evening meal on 12/02/10, which resulted in the need for nursing staff to administer the Heimlich maneuver to expel a bolus of food that obstructed the resident's airway. This choking episode was an avoidable accident, which resulted from the resident receiving and consuming foods that were not pureed in accordance with his physician-ordered therapeutic diet. Interview with the administrator and director of nursing (DON), on 01/10/11 at 3:20 p.m., revealed Resident #83 had resided on the B wing until 12/02/10, when a decline in his condition promoted the facility to transfer him to C wing where his health status could be more closely monitored. When, during the evening meal on 12/02/10, Resident #83's meal tray did not arrive on the new unit (C wing), nursing staff contacted the dietary department to request another tray. Two (2) residents on C wing (Residents #83 and #100) had the same last name. Dietary staff was not aware of Resident #83's room transfer and prepared a tray for Resident #100 (the other resident on C wing with the same last name). Resident #100 had a physician's orders [REDACTED].#83 had a physician's orders [REDACTED]. Nursing staff then proceeded to serve Resident #83 the mechanical soft diet, which resulted in the choking episode. Nursing staff immediately reacted to the choking by performing the Heimlich maneuver, which successfully dislodged the bolus of food that was obstructing Resident #83's airway. Nursing staff immediately notified the physician of the choking episode and received instructions to monitor the resident. On the following day, the resident sustained [REDACTED]. The administrative staff immediately began an investigation into the root cause of this adverse event. A comprehensive investigation by the facility's administrative staff identified that both dietary and nursing staff was responsible for this avoidable accident. The incident was reported to all State agencies as required. The staff members involved received suspensions, all dietary staff was re-educated on the need to carefully prepare meal trays in accordance with each resident's physician-ordered diet, and all nursing staff was re-educated on the need to verify that mechanically altered diets were correct prior to service to each resident, by reviewing each resident's tray card. The system failures that contributed to this adverse event were identified and corrected by the facility prior to this on-site complaint investigation by the State survey and certification agency. | 2014-07-01 |