| 51 |
GUARDIAN ELDER CARE AT WHEELING |
515002 |
20 HOMESTEAD AVENUE |
WHEELING |
WV |
26003 |
2018-05-03 |
689 |
D |
1 |
1 |
X20F11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review, the facility failed to provide adequate supervision in accordance with the resident's plan of care to prevent accidents. Specifically, two (2) residents reviewed for Accidents, the facility failed to follow aspiration precautions when each was allowed to use a straw despite physician's orders [REDACTED]. Resident identifiers: #93 and #8. Facility census: 142. Findings included: a) Resident #93 Review of the care plan, dated 3/5/18, revealed Resident #93 had nutritional risks based, in part, on a recent [DIAGNOSES REDACTED]. Review of the current Kardex (care directives provided for and used by Certified Nurse Aides - CNA) revealed Diet: ST (speech therapy) Orders: no straw protocol w/ liquids. The physician's orders [REDACTED]. Observation on 5/2/18 at 8:43 AM revealed CNA #110 place a breakfast tray in front of Resident #93. The CNA set up the resident's meal, including opening the resident's milk carton, placed it in front of him, and left. A straw was observed on the tray. Resident #93 picked up the straw, removed the paper wrap and placed it in the milk carton. He then began to drink using the straw. CNA #105 and #110 both passed by in the next few minutes, but did not intervene. There was no nurse on the unit during this observation. The meal card on the resident's tray did not identify the resident was not to have straws. In an interview on 5/2/18 at 8:52 AM CNA #110 stated she was not aware the resident was not supposed to have a straw. She said she did not think it was identified on the Kardex. At 9:01 AM CNA #105 stated she did not know Resident #93 was not supposed to have a straw. In an interview on 5/2/18 at 10:41 AM Nurses #3 and #82 explained there were three nurses splitting Unit 5 today. They explained there were extended periods of time they would each be on their other respective units, and so no nurse would be present on Unit 5. Both stated they were not aware Resident #93 should not have a straw, however they were able to locate the physician's orders [REDACTED]. In an interview on 5/02/18 at 11:02 AM, Speech Therapist #158 stated Resident #93 should not have straws as she did not believe his swallow reflex was fast enough to compensate if he had issues. She stated she had not been notified of any coughing or choking that might be related to the resident's use of straws and did not believe he had experienced any ill effects, however she stated he should not be provided one or allowed to use them. b) Resident #8 Observation on 5/02/18 at 5:01 PM revealed Resident #8 propel his wheelchair out of his room. He stated loudly, They took my straws! He explained he had straws in his room that he used daily, I have to drink a lot of water . I had straws but someone came in while I was out of my room and took them. He stated he had been using straws for months. CNA #65 stated she had heard there were issues with residents using straws and she remembered Resident #8's care plan directed he should not have any so she took them. She verified the resident had straws in his room that he used daily, She did not know how long he had been using them, but stated, awhile. According to the 1/24/18 quarterly Minimum Data Set, the resident had a Brief Interview for Mental Status score of 15, indicative of no cognitive loss. The MDS (Section K) revealed the resident exhibited no signs or symptoms of a swallowing disorder. According to the 12/20/16 Modified [MEDICATION NAME] Swallowing Study, located in the resident's record, strategies identified to address the resident's swallowing difficulties included no straws. A physician's orders [REDACTED]. NO STRAW. CUE PT TO USE CHIN TUCK. Review of the most current Kardex revealed thin/regular liquids. Cup only, no straw, cue pt (patient) to use chin tuck. According to the Alteration in Nutrition Care Plan, updated 2/12/18, Resident #8 had a [DIAGNOSES REDACTED]. Interventions included Regular Diet, regular texture, thin/regular liquids. Cup only, no straw, cue pt to use chin tuck; Encourage 6 to 8 glasses of water per day; Suction cup to be provided at all meals. In an interview on 5/03/18 at 9:35 AM, the Administrator and Director of Nursing (DON) stated staff should follow the care plans. They verified Resident #8 should not have had straws according to his most current orders. In an interview on 05/03/18 at 11:13 AM, Therapist #139 reviewed Resident #8's therapy notes. She stated Resident #8 should not have straws. She verified that order was current and based on his last skilled speech therapy services. In an interview on 5/3/18 at 12:50 PM, the Assistant DON #88, stated there had been no observed swallowing issues for Resident #8 since his diet had been upgraded. She stated staff are expected to follow physician's orders [REDACTED]. |
2020-09-01 |