The following reflects the findings of the Department of Public Health during a Complaint Investigation visit.
CLASS AA CITATION -- DIETARY
72339 Dietetic Service-Therapeutic Diets. Therapeutic diets shall be provided for each patient as prescribed and shall be planned, prepared and served with supervision and/or consultation from the dietitian. Persons responsible for therapeutic diets shall have sufficient knowledge of food values to make appropriate substitutions when necessary.
The Facility failed to prepare and serve Resident 1's therapeutic diet (mechanical soft) as prescribed.
On 11/20/08, an investigation of an entity reported event was conducted for complaint # CA00169920 after Resident 1 choked on a whole meat ball and was not successfully resuscitated.
Resident 1 was a 54 year old male who was admitted on 6/21/06 with diagnoses that included dementia (mental disorder with general loss of intellect) and schizophrenia (mental disorder with delusions, hallucinations). Resident 1 had a history of dysphagia (difficulty swallowing) as evidenced by the nursing assessment document dated 6/21/06 and as evidenced by the assessment form from referring facility dated 3/19/06. The Minimum Data Set (MDS) Assessment dated 7/03/06 indicated Resident 1 required supervision and oversight with eating.
Physician orders dated 6/21/06 indicated, "Regular Mechanical soft diet..." Physician orders dated 2/12/07 indicated, "Have patient to have his meals in dining room." A physician progress note dated 4/10/07 indicated, "Patient stuffs his mouth [with] food & seems to have trouble swallowing, will order swallow study. " There was no documented evidence that a swallow study was completed.
The facility's "Reported Event" administrative document dated 12/11/08 was reviewed. On 11/19/08, a noon meal tray was prepared for Resident 1 by Cook 1. Cook 1 prepared a diet tray consisting of spaghetti with two whole meatballs, tossed salad, roll, two cookies and milk. The meal tray was then transferred to a transport cart and Certified Nurses Aide (CNA) 1 provided the meal tray to the resident at 12:00 P.M., in his room. At approximately 12:30 P.M., Resident 1 approached Licensed Nurse (LN) 1 in hallway B coming from his room. Resident 1 walked toward the LN 1 and held on to the medication cart. LN 1 noticed Resident 1 was pale and was unable to speak. Resident 1 began to fall and LN 1 assisted Resident 1 to the ground. LN 1 observed Resident 1's jaws were locked. LN 1 was unable to open his mouth. LN 1 then began the Heimlich Maneuver. (A medical procedure preformed on a person to free foreign objects caught in the throat). LN 1 was assisted by the Director of Nurses (DON) and the DON began to administer cardiopulmonary resuscitation (CPR). LN 1 then called 911.
During review of the Emergency Medical Services (EMS) call report dated 11/19/08, EMS arrived at the facility at 12:34 P.M. "Upon arrival, CPR was continued & pt (patient) unable to ventilate (instill air into the lungs). Pt's airway suctioned & food removed. Pts (patients) airway then re-opened and large amounts of food were removed & a large meatball removed. Pt then intubated, (tube placed into the airway to assist in breathing) loaded, & transported to RMC."
The "Emergency Room Code Blue" record dated 11/19/08 indicated Resident 1 arrived at 1:00 P.M. on 11/19/08. The code blue record, indicated CPR continued until 1:19 P.M., at which time the code blue was discontinued. "Outcome: Expired."
The County Coroner "Certificate" and "Verdict" for Resident 1 dated 1/1/09 revealed, "Cause of Death: Asphyxia due to Aspiration of Food Bolus...the decedent choked on a bolus of food..."
Physician orders dated 2/12/08 indicated a "Mechanical Soft diet" and "Encourage Resident to have his meals in the dining room." The Nutritional Progress note dated 8/08 for Resident 1 was reviewed on 12/10/08. The progress note indicated, "encourage resident to have meals inside the dining room."
During an interview on 11/20/08 at 3:45 P.M., the Dietary Supervisor (DS) stated, Cook 1 did place 2 whole meatballs on Resident 1's noon meal tray. The DS stated, Certified Nursing Assistant (CNA) 1 provided the meal tray with 2 whole meatballs to Resident 1. The DS stated, Cook 1 and CNA 1 should have checked the dietary order card to ensure the meatballs served were "mashed up" and not whole. During an interview on 12/12/08 at 2:10 P.M., the DS stated the cook who plated the meal should have cut up Resident 1's meatballs into small bite size pieces. The DS stated if the cook failed to cut up the meatballs, then the CNA who passed out the meal tray should have cut up the meatballs. Review of the "Mechanical Soft" policy and procedure on 11/20/08, indicated, "All meat (including poultry and pork) should be ground or chopped."
Review of the facility's menu for meatballs was reviewed on 11/20/08. The menu indicated, meatballs were to be ground for a mechanical soft diet.
Review of the cook's menu on 12/11/08, for meatballs/tomato sauce indicated, "Mech Soft: Grind portions needed to desired consistency."
During an interview with Cook 1 on 12/11/08 at 2:24 P.M., Cook 1 stated, a mechanical soft diet meant the food was to be fine chopped or sliced. Cook 1 stated she did not chop or ground the meat ball on Resident 1's meal tray. Cook 1 stated she felt because the meat ball was made of ground meat, this was okay for a mechanical soft diet. Cook 1 stated she had the weekly cook sheet which did indicate to ground up the meatballs but just did not think about it.
Review of the facility's Cook Job Description on 12/11/08 indicated, "To prepare food in accordance wi t h prescri bed resi dent di et specifications...Prepare and serve food and meals in accordance with planned menus, diet plans..." The "Employment Development Department #1450" administrative document dated 12/9/08 indicated the facility acknowledged Cook 1 failed to read and follow the lunch menu and failed to follow the directive on the resident's diet card on type/consistency of food. The document noted, "[Cook 1] did not follow the facility's menu for the residents, not ensuring that those that are on special diets received the right food. [Cook 1] failed to prepare on 11/19/08 "mechanical soft" servings for the residents that required it, as a result of her negligence, one resident choked with a fatal outcome."
During an interview on 12/12/08 at 12:05 P.M., CNA 1 stated, she cared for Resident 1 about 50% of the time she worked at this facility. CNA 1 stated she worked for the facility for about 1 year and 5 months. CNA 1 stated a mechanical soft diet called for meat to be chopped or ground up. CNA 1 stated she provided Resident 1 with his meal tray with two whole meatballs on 11/19/08. Resident 1 was located in his room as he always ate in his room. CNA 1 stated Resident 1 was unsupervised for his meals. The meal tray included spaghetti with two whole meatballs, salad, roll, two cookies and milk. CNA 1 stated Resident 1's diet card indicated he was to have a mechanical soft diet. CNA 1 stated, "I just did not think to chop up his meat that day." CNA 1 stated she thought the reason Resident 1 was on a mechanical soft diet was because he frequently stuffed his mouth with food.
During an interview on 12/10/08 at 3:10 P.M., Licensed Nurse (LN) 1 stated she felt the reason the physician ordered Resident 1 to have meals in the dining room was because it was unsafe for Resident 1 to eat by himself. Resident 1 had behavioral issues of putting lots of food in his mouth at one time.
During an interview on 2/12/08 at 1:15P.M., the DON stated she thought the order to encourage Resident 1 to eat in the dining room was for Resident 1's safety as he stuffed food into his mouth.
During an interview with the DON on 12/30/08 at 1:35 P.M., she stated she was aware of the physician's progress note dated 4/10/08 requesting a swallow study. She stated there was no follow up on the physician's suggestion and no swallow study was preformed.
Resident 1 was a 54 year old male with a physician's order for a mechanical soft diet and to eat in the dining room with supervision. Resident 1 had a history of difficulty swallowing and stuffing his mouth with food. On 11/19/08, Resident 1 was served two whole meatballs instead of chopped up meatballs for his noon meal, in his room without supervision. Resident 1 choked on his meatballs and the staff attempted the Heimlich maneuver and CPR without success. EMS was dispatched, transported Resident 1 to the acute care hospital and Resident 1was pronounced dead in the emergency room.
The above violation presented an immediate danger to the resident and was a direct proximate cause of the resident's death and therefore constitutes a class 'AA' citation.