The following reflects the findings of the Department of Public Health during a Complaint Investigation visit. Representing the Department of Public Health: ??, EvaluatorCLASS AA CITATION -- PATIENT CARE
72311 (a)(1)(C)(2)(3)(B) 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:
(C) Reviewing, evaluating and updating of the patient care plan as necessary, by the nursing staff and other professionals involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition.
(2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan.
(3) Notifying the attending physician promptly of:
(B) Any sudden and/or marked adverse change in signs, symptoms, or behavior exhibited by a patient.
The facility failed to ensure that nursing service reviewed and revised the plan of care for Patient A, after he was observed having difficulty swallowing thin liquids. The facility also failed to notify the physician when Patient A was identified to have problems with swallowing thin liquids. There were no changes made in the consistency of fluids and/or food provided for Patient A. On 11/30/08, Patient A choked during lunch and died.
Patient A was admitted to the facility on 10/28/08 with diagnoses that included diabetes, dementia, and history of a stroke in 2002. According to a Discharge Summary from the general acute care hospital, dated 10/28/08, Patient A was discharged on a "diabetic diet with PM (evening) snack with aspiration precautions."
On admission to the skilled nursing facility, Patient A's diet order read, "Regular NCS (no concentrated sweets), NAS (no added salt) diet." On 10/28/08, the facility developed a plan of care related to Nutritional Status. The care plan goal was for the patient to have no signs and symptoms of aspiration/choking daily for 3 months. The approaches to the plan included: "Dietary/Nsg. (nursing) to assess texture of food and notify MD (doctor, physician) if not tolerated, Dietitian to visit resident PRN (as needed), Allow enough time to chew and swallow." There was no plan to monitor Patient A for signs and symptoms of aspiration during meals based on the care plan goal.
On 11/3/08, the dietary supervisor and the registered dietitian wrote on the Nutritional Screening notes, "Poor dentition, however tolerating po (oral) s (without) chewing difficulty per nursing." On 11/26/08 at 9:50 A.M., LVN 1 wrote in her nursing notes, "Left mssg (message) for [representative] from [insurance] for OK for speech eval (evaluation), need auth. (authorization) from [insurance secondary] res. (resident/patient) noted to freq. (frequent) coughing c (with) thin liquids, awaiting C/B (call back)."
Other than the above nursing notes, there was no other documentation of any observation that Patient A had problems swallowing thin liquids. There was no documentation in the nursing notes to indicate that the physician was notified of Patient A's difficulty swallowing. There were no physician orders received for diet modification and/or changes to Patient A's diet. There was also no indication in the record that Patient A's plan of care was reviewed and revised to reflect interventions for the patient's swallowing problem.
During an interview on 12/15/08 at 11:40 A.M., LVN 1 was asked about the nursing entry that she wrote on 11/26/08. LVN 1 said that Patient A coughed with "thin liquids." LVN 1 said that she noted this on 11/25/08, the day prior to calling for an authorization for a speech/swallowing evaluation. "They (insurance) couldn't send anyone out. I relayed that to the speech therapist here. I don't remember what she told me." LVN 1 said that she could not remember when this was reported to the speech pathologist at the skilled nursing facility. LVN 1 also stated that she did not notify anyone else at the facility of Patient A's difficulty swallowing. LVN 1 confirmed that she did not notify the physician of Patient A's difficulty swallowing.
In an interview on 12/15/08 at 12:20 P.M., the speech pathologist stated that she was informed of the speech/swallowing evaluation after Patient A expired. "She (LVN 1) told me that the [insurance] didn't authorize me to see him (Patient A)."
On 11/30/08, Patient A was in the assisted dining room for lunch. There were two certified nursing assistants (CNA) in this dining room to assist and observe eleven patients. Patient A was served a regular diet with no concentrated sweets and no added salt as per the physician's original order on admission. During an interview on 12/15/08 at 9 A.M., the dietary supervisor said that Patient A's lunch consisted of beef with barbeque sauce, steamed cabbage and carrots, and mashed potatoes. The dietary supervisor said that the patient also received regular fluids, not thickened.
CNA 1 was interviewed on 12/15/08 at 11 A.M., and CNA 2 was interviewed on 12/17/08 at 7:49 A.M. CNA 2 said that she cut Patient A's meat. Sometime during lunch, Patient A began coughing. CNA 2 said that she asked Patient A if he was "OK" and he responded, "Yes." She said, "He was still chewing. Still coughing." Both CNAs stated that Patient A was removed from the dining room as he "slumped" in the wheelchair. CNA 2 described and demonstrated how she performed an abdominal thrust, a fist punch to Patient A's mid thoracic area. CNA 2 said that the attempt was unsuccessful, and that Patient A was unresponsive. The CNAs said that LVN 1 responded to the call for assistance. LVN 1 performed several attempts at the Heimlich maneuver. CPR (cardio pulmonary resuscitation) was started. The facility called 911, the paramedics arrived at 1:12 P.M. According to the paramedic report, Patient A was initially noted to be "apneic (no breathing) and pulseless (no pulse)." After unsuccessful ALS (advanced life support) care, Patient A was pronounced at 1:29 P.M.
The autopsy report for Patient A, dated 12/4/08, showed that a "Soft food bolus completely occluded the distal trachea (wind pipe) just above the carina as well as the right main stem bronchus. Microscopic examination of the lungs documented a background of emphysematous change with focal areas of older early organizing pneumonia with vegetable debris and multinucleated giant cells consistent with previous aspiration." The cause of death was asphyxia [suffocation] due to aspiration of food bolus.
These violations presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and were a direct proximate cause of the death of the patient.