| 9247 |
WHITE SULPHUR SPRINGS CENTER |
515100 |
ROUTE 92, PO BOX 249 |
WHITE SULPHUR SPRING |
WV |
24986 |
2011-05-19 |
323 |
J |
0 |
1 |
UNLT11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, medical record review, and staff interview, the facility failed to assure that one (1) of twelve (12) Stage II sample residents received the necessary supervision and positioning to prevent choking / aspiration during oral consumption. Resident #14, a [AGE] year old male with [DIAGNOSES REDACTED]. The resident was discovered slumped sideways in his bed at 9:15 a.m. on 05/11/11, with his breakfast tray on an overbed table above his abdomen. His head, right arm, and right shoulder were pressed against the siderail of his bed, with the call bell wedged under his right side between the mattress and siderail. The resident was noted to have partially masticated eggs on his chin and on the front of his shirt. He complained of having choked on his eggs. The resident was unable to reposition himself away from the siderail when cued. Interviews with staff members revealed the resident had experienced an episode of choking earlier the same morning, with staff intervening and repositioning him in the bed. The resident was left unsupervised to continue to eat until discovered by this nurse surveyor. review of the resident's medical record revealed [REDACTED]. Staff was aware he would frequently refuse to get out of bed for meals, and he was evaluated by a speech language pathologist (SLP) to see what could be done to promote safe eating and drinking while in bed. A recommendation was made to have him sitting in an upright position in bed with pillow positioning under his right side to assist him in maintaining this upright position, but this recommendation was not incorporated into the resident's care plan. In fact, his care plan was not revised at all to address his frequent refusals to get out of bed for meals. With regard to the amount of supervision Resident #14 was to receive during meals, the SLP's recommendation for distant supervision was made based on the need to consider the availability of nursing staff. When asked what kind of supervision the SLP would have recommended if nursing staffing was not a consideration, the SLP stated she would have recommended Resident #14 be kept under close supervision which would have required him to be within eyesight of staff members at all times while consuming an oral diet or liquids. The administrator was informed at 10:45 a.m. on 05/11/11 that failing to provide for appropriate positioning and necessary supervision when the resident was eating in bed placed Resident #14 in immediate jeopardy of harm or death from choking / aspiration. The immediate jeopardy was removed at 12:20 p.m. on 05/11/11, following an assessment of the resident's condition and implementation of a plan to assure appropriate positioning and supervision during consumption of food or fluids by Resident #14. There was no deficient practice identified following the implementation of the facility's interventions to assure resident safety during oral consumption. Resident identifier: #14. Facility census: 61. Findings include: a) Resident #14 While standing in the corridor outside of Resident #14's room on 05/11/11 at 9:15 a.m., this nurse surveyor observed Resident #14 in his bed slumped toward the right with his head on the siderail. After entering his room, observation found an overbed table placed across his abdominal area with his breakfast tray on top. His head, right arm, and right shoulder were pressed against the siderail of his bed, two (2) pillows were noted on the left side of the resident, and the call bell was wedged under his right side between the air mattress and siderail. The resident had a lift pad beneath him, which did not offer resistance to sliding when in contact with the surface of the air mattress. The resident was noted to have partially masticated eggs on his chin and on the front of his shirt. He complained of having choked on his eggs. The resident was unable to reposition himself away from the siderail when cued. A nursing assistant (NA - Employee #70) responded to a request for assistance. She assisted the resident to move away from the siderail and retrieved the call bell from between the siderail and the air mattress. After repositioning Resident #14, Employee #70 brushed back his hair with her hand, revealing a rectangular reddened area in the shape of the top of the siderail above the resident's right ear. When asked, Employee #70 stated she would report this reddened area to his nurse. She stated the resident chokes easily but had refused to get up that morning. -- An interview with the licensed practical nurse (LPN) responsible for the resident (Employee #27) was conducted at 9:22 a.m. on 05/11/11. She stated the resident had choked earlier, and she and another NA had assisted him to reposition in the bed. She stated she stayed with him until the resident cleared his throat, and then she left to continue her medication pass. Review of information collected by the facility on 05/11/11 found that Employee #1 was identified as the NA who assisted Employee #27 that morning. Review of the facility's documentation found the NA had delivered the resident's breakfast tray to his room at approximately 8:30 a.m. on 05/11/11. The NA returned to the resident's room approximately five (5) minutes later after hearing the resident cough. The resident was leaning to the left, so she pulled him to the middle of the bed and got Employee #27 to assist. -- Record review revealed the following nursing note, entered two (2) hours after Resident #14's second choking episode by a corporate nurse consultant at 11:30 a.m. on 05/11/11 (quoted as typed), Resident was assessed following a choking episode during morning meal. No signs of distress. No reddened area to (r) side of head as indicated by the surveyor observation. -- Record review revealed this [AGE] year old male was most recently readmitted from the hospital to the facility on [DATE] where he had been treated for [REDACTED]. His active [DIAGNOSES REDACTED]. Review of Resident #14's most recent assessment, a quarterly minimum data set (MDS) with an assessment reference date (ARD) of 04/06/11, found in Section G that he required the extensive physical assistance of two (2) or more persons for bed mobility, was totally dependent on two (2) or more persons for transferring, required the extensive physical assistance of one (1) person with eating, required human assistance to stabilize when transferring between surfaces, and had impaired functional limitation in range of motion of his upper extremity on one (1) side. Review of Section K found the resident displayed coughing or choking during meals or when swallowing medications. Review of his previous two (2) MDSs, a Medicare 5-Day MDS with an ARD of 03/21/11 and a Medicare 14-Day MDS with an ARD of 03/26/11, revealed in Section G that he required the extensive physical assistance of two (2) or more persons for bed mobility, was totally dependent on two (2) or more persons for transferring, required the extensive physical assistance of one (1) person with eating, required human assistance to stabilize when transferring between surfaces and when moving on and off the toilet, and had impaired functional limitation in range of motion of his upper and lower extremities on one (1) side. Review of Section K found the resident displayed coughing or choking during meals or when swallowing medications. -- Review of Page 3 of 24 of the current care plan found the following problem statement (Date Initiated: 11/12/10; Revision on: 04/13/11) (quoted as typed): restorative program for up in w/c (wheelchair) for all meals per program plan. The goal associated with this problem statement was (quoted as typed): Follow OOB (out of bed) schedule to be up in w/c for meals. The interventions developed to assist the resident in achieving this goal were (quoted as typed): Assist patient in sitting upright in w/c for all meals. Explain task to resident prior to activity. Provide supervision with meals. Review of Page 16 of 24 of the current care plan found the following problem statement (Date Initiated: 08/16/08; Revision on: 04/13/11) (quoted as typed): Resident has impaired swallowing due to dysphagia and is edentulous - Resident is at risk for aspiration, chokes easily. The goal associated with this problem statement was (quoted as typed): The resident will be free from signs and symptoms of possible aspiration thru next review. The interventions developed to assist the resident in achieving this goal were (quoted as typed): Honor food preferences within meal plan. Provide diet as ordered (family aware of choking,waiver was signed). Provide thickened consistency liquids as ordered. Place resident in 90 (symbol for 'degree') upright position / out of bed when swallowing food or drink. Encourage resident to take small sips / bites. Observe for signs / symptoms of aspiration. Place call light within reach at all times. Supervise / cue / assist as needed with meals. Elsewhere in the care plan, the following interventions were found in association with other problem statements: - On Page 2 of 24 - Observer (sic) resident safety, his diet and watch for choking. - On Page 5 of 24 - Provide supervision with meals after set up. Assist as needed. The care plan did not address how staff was to ensure Resident #14 maintained an upright position at 90 degrees while consuming food / fluids in bed, nor did it provide guidance as to how much supervision to provide the resident when consuming food / fluids. -- An interview was conducted on 05/11/11 at 10:10 a.m. with the registered nurse (RN - Employee #43) who authored the care plan. She stated the resident was in the restorative program to be up in his wheelchair for all meals so he could be supervised while eating. She conveyed that the resident refused to get up / out of bed for meals at times. When asked if a care plan had been developed to assure the resident's safety while eating in bed, she stated that no such plan had been developed. -- An interview with the individual identified by the facility as the occupational therapist (OT - Employee #91) was conducted at 10:48 a.m. on 05/11/11. Employee #91 stated the resident was really a high aspiration risk and the plan was for him to be supervised in the dining room for all his meals. -- Review of the 04/27/11 care plan meeting note written at 1:52 p.m. found the following: .The resident continues to be very high risk for aspiration. At times, he refuses to get out of bed for meals. He expresses understanding of the importance of getting out of bed for meals, and he understands how he needs to be up to reduce the risk for aspiration. He still refuses at times to get up. He is to be supervised with eating / drinking. Review of the physician determination of capacity form in the medical record found that the attending physician determined, on 02/21/11, that Resident #14 lacked sufficient mental or physical capacity to appreciate the nature and implications of health care decisions. -- Further review of the medical record found an evaluation by the speech language pathologist (SLP) for the treatment period from 12/28/10 through 01/26/11. The SLP identified [DIAGNOSES REDACTED]. Her assessment found the resident demonstrated impairment in the following areas: dry swallow, reflexive cough, reflexive throat clear, volitional throat clear, volitional cough, and gag reflex. The assessment recommended distant supervision during consumption of food / fluids for safety. Additionally, a progress note recorded by a SLP on 12/31/10 stated (quoted as typed): . Swallowing Therapy ( ) to assess and modify positioning to enhance swallow function including repositioning the patient in bed, with head of bed elevation and pillow positioning under right sid eof body to increase ability to sustain midline position. (Note: The SLP who recorded this progress note was not the same SLP who also served as the therapy program manager.) -- An interview was conducted with the therapy program manager / SLP (Employee #85) at 9:10 a.m. on 05/12/11, in the presence of two (2) other nurse surveyors. She stated Resident #14 was a chronic aspirator, his aspiration was significant, and he can aspirate on his own saliva. She stated the resident has a very large, weak tongue which affects his swallowing, and it was a significant danger to him to consume an oral diet, but the family refused PEG tube placement. She stated she tried to make the best out of a really difficult situation. She recommended safe swallowing strategies and education for the NAs. She stated occupational therapy (OT) had a long-standing restorative program to encourage him to get up for meals. He frequently refused meals and frequently refused to get up out of bed for meals. She stated she tried to make the best out of a really difficult situation. She relayed that, when taking staffing concerns into consideration, she recommended he be sitting upright at 90 degrees with distant supervision. When asked what her recommendation would have been if she did not have to take staffing levels into consideration, she stated she would have recommended he be kept under close supervision which would have required him to be within eyesight of staff members at all times while consuming an oral diet or liquids. When asked, she stated that evidence of choking included obvious signs of distress during eating, such as coughing. -- Review of witness statements from staff, obtained by the facility after Resident #14's second choking incident on the morning of 05/11/11, found the following: Statement from Employee #1, obtained during a telephone interview conducted by the director of nursing (DON) at 3:45 p.m. on 05/11/11 and signed by the employee on 05/12/11 (quoted as written): . (Employee #1) stated at about 8:30 a.m., she went in and set up residents tray for him. She asked him if that was OK and he said yes. States his call light was in his lap when she left. Approximately 5 minutes later she heard him cough & went back in to check on him. He was leaning to the left so she pulled him to the middle of the bed. She then got the nurse (Employee #27), LPN to help pull him up higher in the bed & put a pillow behind his head. H.O.B. (head of bed) was adjusted as high as it would go. Asked him again if he was OK and he nodded yes. His call light was in his reach when she left. She was unaware resident should have constant supervision. Statement written by Employee #27, signed and dated on 05/11/11 (quoted as written): In hallway passing meds when CNA (certified nursing assistant) called for assist to pull resident further up in bed. BKF (breakfast) tray was on bedside table - resident was eating prior to entering room, coughing episode was in progress when I entered the room. CNA & I pulled resident to head of bed placed a pillow behind his back to sit him more forward to eat. Resident was able to clear his throat on his own while CNA & I were in the room. When resident was OK, CNA pulled BKF tray to resident. I asked resident 'Are you OK' resident nodded his head yes. CNA & myself left the room. I returned to hallway to do med pass, did not hear resident cough while on 300 hall. Call light within reach. Based on the above statements, there was no evidence Employees #1 and #27 were aware of the need to place pillows under the resident's right side to assist the resident in maintaining a midline position when sitting upright in bed. -- Staff was aware that Resident #14 was at high risk for choking / aspirating food and fluids and that he would frequently refuse to get out of bed and sit in an upright position in a wheelchair for meals. The interdisciplinary team failed to develop interventions for staff to follow when Resident #14 refused to get out of bed for meals (to eliminate safety hazards over which the facility had control to prevent choking while the resident consumed food / fluids in bed), to include the application of pillow positioning under the right side to increase the resident's ability to sustain a midline position when sitting upright in bed. Staff left Resident #14 unsupervised following an episode of the resident sliding in the bed and choking / coughing during his morning meal. The failure to assure the resident remained in an upright position with staff supervision during the remainder of the morning meal on 05/11/11 placed this resident at risk of harm or death from aspiration. |
2016-01-01 |