The following reflects the findings of the Department of Public Health during a Complaint Investigation visit. Representing the Department of Public Health: ??, HFEN
CLASS AA CITATION -- PATIENT CARE
72311(a)(1)(A) Nursing Service - General
(a) Nursing service shall include, but not be limited to, the following:
(1) Planning of patient care, which shall include at least the following:
(A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission.
72311(a)(1) Nursing Service - General (a) Nursing service shall include, but not be limited to, the following:
(1) Planning of patient care, which shall include at least the following.
72311(a)(2) Nursing Service - General
(a) Nursing service shall include, but not be limited to, the following:
(2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan.
The facility failed to ensure nursing care included a continuing assessment of Patient A. On 9/9/08, Patient A choked when he was fed the incorrect diet and choked on a partially consumed sandwich, which he obtained from the nourishment cart later that same day. However, there was no documented evidence Patient A was assessed for possible aspiration. In addition, there was no documented evidence of administration of emergency treatment for choking and/or aspiration.
The facility failed to implement the care plans that addressed Patient A's dysphagia (difficulty with swallowing). The care plans stipulated Patient A receive a therapeutic diet and staff provide caregiver training and safety during meals. On 9/9/08, Patient A had two episodes of choking when he received the incorrect diet for dinner and consumed part of a sandwich later in the evening. As a result, Patient A died; the patient's death was determined to be caused by "mechanical asphyxiation" secondary to aspiration of a food bolus.
Patient A was admitted to the facility on 7/25/08, with diagnoses that included status post left hip ORIF (open reduction internal fixation), dementia and gastro esophageal reflux disease. On 8/21/08, a diagnosis of dysphagia was added to the health record.
An H&P (history and physical) dated 7/26/08, described Patient A as incapable of making his own healthcare decisions. Patient A's daughter was listed as the individual responsible for making healthcare decisions and life sustaining treatment choices.
The patient's health record contained a document dated 8/11/08 and signed by Patient A's daughter. The document outlined the patient's wishes, such as CPR, life sustaining treatments and acute care hospital transfers. According to the patient's wishes, CPR (cardiopulmonary resuscitation) would not be performed, "...in the event of a medical emergency, where the patient was determined to be in an "irreversible unconscious or persistent vegetative state; or (2) terminally ill ... or (3) other circumstances arise where burdens of the treatment outweigh expected benefits to the [patient]."
Physician's admission orders, dated 7/25/08, included a therapeutic diet, described as puree and honey-thickened liquids. In addition, the physician stipulated all crushable medications were to be crushed before administration.
On 7/25/08, a plan of care was initiated to address Patient A's ADL (activity of daily living) requirements. Patient A was determined to be "totally dependent" upon staff for all ADLs, such as hygiene, bed mobility and transfers to and from his wheelchair.
On 7/26/08, the physician ordered "swallow treatments" daily, five times a week, for four weeks, which included "direct dysphagia treatment...ongoing swallow analysis, diet modification, as needed, OM (oral motor) tasks; compensatory...strategies; thermal stimulation; caregiver instruction."
On 7/26/08, a plan of care was initiated by the SLP (speech language pathologist). The treatment plan reiterated the physician's order for "swallow treatments."
On 8/21/08, Patient A underwent a "Videofluoro Swallow Study" as ordered by the physician. The following "impression" was included within the test results, "[Patient A] presents with moderate oral pharyngeal phase dysphagia, silent aspiration with nectar thick liquids and thin...mealtime protocol must include puree and honey thick liquids...encourage [Patient A] to cough/clear at end of meal...family reports incidences of staff attempting to feed patient bread/solids...make sure his tray is checked for proper consistency of food/liquids..." In addition, documentation included, "recommendation comment: "...high risk for aspiration, particularly with thin, nectar thick liquids...must not be fed fast...must be fed puree and honey thick liquids...crush meds when possible..."
On 8/22/08, the physician re-ordered swallow treatments, "to focus on caregiver instruction and safety while eating."
On 8/25/08, the physician ordered RNA (restorative nurse assistant) feeding program.
On 8/28/08, the physician discontinued swallow treatments by the speech therapist, as Patient A's "current potential reached."
On 9/1/08, the plan of care that addressed Patient A's dysphagia was updated to include, the use of a "Nosey" (special drinking cup) cup and "prn" (as needed) suctioning of the patient's oral secretions.
Review of the MAR (medication administration record) revealed the licensed nurse checked the patient's therapeutic diet, for all three meals, from 9/1/08 through 9/9/08.
On 9/9/08 at 1715 hours, the licensed nurse documented Patient A was observed in the dining room, "for feeding program...visited by the daughter at meal time...consumed 30% of the dinner tray."
At 1745 hours, the licensed nurse documented Patient A was observed in the hallway of Station II. According to the documentation, the patient's daughter left for home. The licensed nurse documented "alert and responsive to pain and tactile stimuli...as usual, behavior problem arise when reposition for comfort in the wheelchair."
At 1950 hours, the licensed nurse documented, "when C.N.A. (certified nurse assistant) was about to put him [Patient A] back to bed for HS (hour of sleep) care, heard C.N.A. called for help...immediately checked and assisted [Patient A] ... noted with SOB (short of breath) and getting bluish cyanosis...called 911...after 5 minutes paramedics arrived....took over."
However, there was no documented evidence the icensed nurse assessed Patient A to determine whether or not the patient aspirated. In addition, based on the licensed nurse's documentation, emergency treatment, such as administration of oxygen and/or suctioning, was not provided.
The following documentation was included within the "Emergency Medical Services" report dated 9/9/08. EMS was summoned by facility staff at 2003 hours; EMS personnel arrived at 2007 hours. Under the heading "Chief Complaint," the following was documented, "Cardiac arrest for greater than 10 minutes...found lying on bed in F/A (full arrest)." Patient A was described with cyanosis and levidity (pooling of blood) to the back, spine and pelvis areas and pupils were fixed and dilated. The area titled "Treatment/Response," included "DNR (do not resuscitate) provided by staff...base contact made and advised to discontinue any ALS (advanced life support) intervention." At 2027 hours, documentation revealed no pulse, no respirations, no blood pressure and EKG "asystole" (no heartbeat).
An unsigned "Record of Death" was discovered in the patient's health record. Patient A's "principle cause of death" was listed as "cardiac arrest."
On 11/25/08, Patient A's daughter forwarded a copy of the certificate of death to the Department; along with a written request for an investigation into the death of Patient A.
On 12/10/08 at approximately 0900 hours, an interview was conducted with an administrative nursing staff. Staff was asked about an investigation into the death of Patient A. Staff stated that as the patient was a DNR and died of an apparent heart attack, an investigation was not required.
On 12/10/08 at 1015 hours, during an interview with an administrative staff, staff stated on 9/9/08, Patient A received a mechanical soft rather than a pureed diet. Administrative staff described the events as told to her. In the dining room, Patient A started to cough; the RNA stopped feeding the patient and called the charge nurse. Patient A consumed about "1-2 bites" of rice and vegetables. When the charge nurse arrived, Patient A was administered thick liquids, a puree diet and ate 30% of the meal without further coughing. After the meal, staff stated the patient's daughter wheeled patient A to the front lobby, where he stayed until his daughter left. Shortly after that, Patient A was observed "cyanotic;" the patient was put to bed, given oxygen and CPR was initiated.
On 12/10/08 at 1040 hours, an interview was conducted with the RNA who fed Patient A his dinner meal on 9/9/08. RNA 1 stated the patient's meal tray contained the incorrect diet; a "mechanical soft" diet was served. According to RNA 1, Patient A consumed one spoon full of vegetables and rice before he began to cough. RNA 1 called the charge nurse, who assessed the patient and told him to cough. After that, the charge nurse fed Patient A 30% of a puree meal. RNA 1 stated the patient's daughter arrived and took Patient A to the lobby for a visit. RNA 1 ended the interview by stating she had previously fed Patient A approximately two weeks prior to 9/9/08 and the patient did "ok."
The facility's "weekly" menu guide for 9/9/08 listed the dinner meal as pepper pot soup, tuna salad sandwich, brownie and beverage.
On 12/10/08 at 1600 hours, a telephone interview was conducted with an administrative staff. Staff stated an investigation was started after the patient's death because there was the possibility of "wrong doing." The facility's "conclusion" was Patient A died as a result of a heart attack.
In addition, administrative staff stated RNA 1 approached her on 12/10/08 and revealed she had been previously told, by a C.N.A., (certified nurse assistant) that Patient A "died because he received bread...the C.N.A. gave him bread." Therefore, administrative staff stated a new investigation was initiated. In addition, administrative staff stated she was informed of the patient's history of "grabbing" food from meal trays and nourishment carts.
On 12/10/08 at 1315 hours, a telephone interview was conducted with LVN1. During the interview, the following was revealed. "I was called to the dining room because he [Patient A] was choking. "I ran there...he was ok...just sitting there...I fed him a little puree...he was ok." However, "at approximately 7:55 p.m., the C.N.A. called for help...patient was gasping for air...trouble breathing...was in his wheelchair." "I told the C.N.A. to put him in bed so I could check him better." "I called 911 but didn't do CPR because he was a DNR....I told [another LVN] to get oxygen...she did....then the paramedics arrived...they took over."
Review of the coroner's "Autopsy Report" was obtained on 12/12/08. The following was included within the report. "There is complete occlusion of the laryngeal orifice by a mass of yellow-white pasty material." The cause of death was "Mechanical asphyxiation, due to aspiration of food bolus in larynx."
On 12/16/08 at 1410 hours, administrative staff contacted the Department and revealed the results of the facility's second investigation into the death of Patient A. Administrative staff stated on 9/9/08, a C.N.A. left the nourishment cart outside a room, within reach of Patient A. As a result, Patient A grabbed a sandwich and began to eat it. "He [Patient A] took a bite and squashed the sandwich when the C.N.A. attempted to retrieve the sandwich...then he started choking and turning colors....staff did all the appropriate actions."
On 12/18/08 at 1626 hours, during a telephone interview with Patient A's daughter, the daughter related her recollection of the events that took place on 9/9/08. Patient A was fed a "regular tray" for dinner and started coughing, one of the C.N.A.s performed the "Heimlich maneuver" and "tomato-like" material was coughed up. After that, a licensed nurse arrived and proceeded to feed the patient a puree meal. After the meal, Patient A appeared sleepy; staff told the daughter the patient would be put to bed to rest. The daughter left the facility at approximately 1800 hours and arrived home by 1900 hours. At 2040 hours, the daughter stated facility staff telephoned her and told Patient A died of a heart attack.
Although Patient A was identified at high risk for aspiration, required a therapeutic diet, as well as "trained caregiver" assistance with meals, the patient was provided with the incorrect diet and consumed part of a sandwich before staff intervened.
Additionally, after Patient A was found unresponsive, facility staff failed to assess Patient A for possible aspiration and failed to provide immediate emergency treatment.
Based on the information obtained, the facility failed to continually assess Patient A and failed to ensure the patient's plan of care (s) that pertained to Patient A's high risk for "silent aspiration," was consistently implemented. As a result, Patient A partially consumed a non-therapeutic diet and evening snack, choked, aspirated and subsequently died.
These facility failures were a direct, proximate cause of death to the patient or resident of the long-term health care facility.