cms_WY: 457
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 457 | WESTWARD HEIGHTS CARE CENTER | 535034 | 150 CARING WAY | LANDER | WY | 82520 | 2018-07-26 | 689 | J | 0 | 1 | 0JZF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, product label and direction information review, and staff interview, the facility failed to implement a system to ensure thickened liquids were provided at the ordered consistency for 2 of 3 residents who received thickened liquids (#22, #155). Observations during the survey showed staff were not knowledgeable about the preparation of nectar-thickened liquids and provided these residents drinks that were too thin, increasing their risk for swallowing and potential aspiration problems. The record reviews for these residents showed they both had recent [DIAGNOSES REDACTED]. This resulted in an immediate jeopardy situation for these residents. The findings were: 1. Review of speech therapy notes showed resident #22 was evaluated on 6/5/17, 11/9/17, and 6/29/18. The notes from these evaluations showed the resident presents with a high risk of aspiration. Review of the 6/29/18 evaluation showed the reason for referral was choking during meal time, and according to the plan the resident would be seen twice weekly for a certification period from 6/29/18 to 9/20/18. Review of the care plan showed the resident had a problem dated 5/18/18 for Potential risk for infection related to dependence for cares, swallowing/aspiration risk . In addition, the care plan identified a problem on 6/19/17 related to Resident is at risk for dehydration r/t (related to) contractures in his hands, dementia, inability to retrieve fluids on his own along with current thickened liquids status. The 9/9/17 intervention for this problem included Thicken all liquids to nectar thick consistency .Ensure proper consistency of fluids at activities, etc .Offer fluids in wavy straw cups .Needs to sit upright for 30 mins (minutes) after meals. The following concerns were identified: a. Observation on 7/23/18 at 5:20 PM showed CNA #1 prepared thickened coffee for the resident by shaking thickening powder from a sugar shaker located on the beverage counter in the dining room. The CNA shook some powder into a wavy straw cup, swirled it and gave it to the resident. At no time did she stir the liquid to check for proper consistency. At 5:27 PM the resident was noted to be coughing. b. Review of the nurse's note dated 7/24/18 and timed at 8:28 AM showed the resident had vomited during the night, had an elevated temperature of 100.5 degrees Fahrenheit (F), and had Fine crackles noted to bilateral bases upon assessment with diminished sounds noted to all other lobes. The physician was contacted for treatment instructions. c. Review of a nurse's note dated 7/24/18 timed at 1:06 PM showed the resident was sent to the urgent care clinic at approximately 9:30 AM and was then sent to the hospital for further evaluation. d. Review of the 7/24/18 hospital discharge instructions showed the resident was diagnosed with [REDACTED]. e. Observation on 7/25/18 at 12:29 PM showed the resident was seated at the dining table, the resident had a cup with thickened water, and also had a cup of coffee. As the resident drank the coffee from the wavy straw cup it was noted to be thin. Interview with dietary aide #1 on 7/25/18 at 12:30 PM revealed the coffee did not look to be nectar-thick, she was not sure who prepared it, and she would prepare a new one. At that time, CNA #2 who was sitting next to the resident to assist with eating got up and retrieved a small portion cup of thickening powder. She added it to the remaining coffee which the resident had been drinking. During interview with CNA #2 at that time she stated the coffee was difficult to thicken. CNA #2 revealed she didn't follow specific directions to add thickening powder, but just added it until it was ready. The CNA had to retrieve more thickening powder to add to the coffee before returning the cup to the resident. f. Interview with the DON and administrator on 7/24/18 at 10 AM verified a contract was in place to provide speech therapy. However, the contracted therapist was on vacation that week. The administrator stated if speech therapy was required while the contracted therapist was on vacation, a therapist could be used from another agency or the hospital. 2. Review of the 6/1/18 quarterly MDS assessment showed resident #155 had a BIMS score of 10/15 (moderate cognitive impairment), required the limited assistance of 1 staff member for eating, and had [DIAGNOSES REDACTED]. Review of the care plan dated 3/6/18 showed the resident had a potential risk for infection related to swallowing issues and was dependent for personal care. The following concerns were identified: a. Review of the medical record showed the resident was admitted to the hospital on [DATE]. Re-admission orders [REDACTED]. b. Review of a nurse's note dated 7/19/18 and timed 12:49 PM showed the resident has been observed to have difficulty swallowing and it was reported to this RN by occupational therapist that resident has been coughing when (s/he) drinks water . The physician was notified and an order was requested for the resident to have nectar-thick liquids. c. Review of a physician communication form dated 7/19/18 showed Resident has been observed to have difficulty swallowing and has been coughing when (s/he) drinks water. We do not have in-house speech therapy until the end of next week. Could we have an order for [REDACTED]. The physician agreed with the request and the order was noted by the DON. d. Review of a Diet order and Communication form dated 7/19/18 showed the resident's diet had been changed to nectar-like thickened liquids. e. Observation on 7/25/18 at 8:40 AM showed the resident was served un-thickened water in a wavy straw cup. Interview with the dietary manager at this time confirmed the water was not thickened and the dietary manager was observed to replace the un-thickened water with prepackaged thickened water. 3. Interview with the consultant RD on 7/24/18 at 2:52 PM revealed she was not aware of the specific thickening/thickened products used by the facility at that time. She stated the speech therapist had provided education in the past related to thickened liquids. The RD further stated the product directions would be expected to be followed to meet the desired consistency. 4. Interview with the CDM on 7/24/18 at 12:33 PM revealed liquids were thickened using a powder contained in a sugar shaker on the counter. The dietary manager demonstrated the procedure by shaking the powder into the liquid and then stirred the beverage until it was the correct consistency; adding more thickener as needed. Further, she stated the facility did not use measuring devices because the amount needed varied depending on the temperature of the liquid being thickened. There was no instructional chart located on the beverage counter. 5. Review of the manufacturer's instructions, provided by the facility, for the thickening powder showed a chart for how much thickener was needed for different amounts and types of liquids to achieve nectar, honey, or pudding consistency. The directions showed for 4 ounces of coffee/tea 3-1/2 to 4 teaspoons should be added. For 8 ounces the amount of thickener was shown to be 7 to 9 teaspoons. The instructions also informed the user to 1. Scoop and level off recommended amount of Thick-It Instant Food and Beverage Thickener using enclosed measuring spoon. 2. Slowly add Thick-It Instant Food and Beverage Thickener to the liquid while stirring briskly with a spoon, fork or whisk until thickener has dissolved. Let thickened liquid stand 30 seconds to 1 minute to achieve desired consistency and serve . 6. On 7/25/18 at 3:03 PM, the administrator was notified of the immediate jeopardy. The facility's removal plan included the following corrective actions: a. Education to all nursing and dietary staff working on 7/25/18 on directions and process for thickening liquids. Additional staff will be educated on the process prior to returning to work. b. Family members of residents who receive thickened liquids were provided education and asked to allow staff to prepare the thickened liquids. c. A monitoring system was put into practice to ensure the physician's orders [REDACTED]. A list of residents with these orders and the thickening directions was placed in a drawer for staff to access in the drink area. The dietary manager or designee was assigned to complete spot checks of the thickened consistency of drinks. The removal plan was accepted on 7/25/18 at 5:33 PM, and the immediate jeopardy was removed on 7/26/18 at 10:08 AM. However, deficient practice remained at a scope and severity of D (isolated noncompliance with potential for more than minimal harm that is not Immediate Jeopardy). | 2020-09-01 |