4525 W. TULARE AVE., VISALIA, CA 93277
Citation Number: 120003543
Citation Date: 8/3/2007
Violation Date: 8/4/2006
Class: AA
Penalty: $ 100000.00

Title 22 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 follow their care plan for dining and dining assistance.

Patient A was a 77 year old female with diagnoses that included dysphagia, (difficulty swallowing). She was admitted to the facility for rehabilitation. Patient A's clinical record contained a physician order dated July 22, 2006, for mechanical soft, ground meat with puree breads, RCS (restricted concentrated sweets), 2 grams sodium, 2 grams potassium, 80 grams protein and nectar thick liquids. On July 27, 2006, per physician order, liquids were upgraded to thin liquids. Patient A's care plan dated July 17, 2006, included the goal: "resident will not have choking during meal time", for Patient A's problems/needs of choking and aspiration. The approaches planned were: 1. restorative dining program, 2. provide cueing, (reminders by staff, to assist resident), 3. Offer sips of liquids between bites, 4. adaptive equipment of divided plate, 5. (lower) rate of intake 6. small bites and small sips, 7. complete oral clearing before next bite, 8. chin tuck with liquid (with liquid upgraded.) These approaches were to be implemented by the Certified Nursing Assistant and Restorative Nursing Assistant staff. Patient A's care plan for dysphagia included approaches to provide diet as ordered, instruct patient to swallow after each bite and monitor for signs and symptoms of aspiration.

On August 8, 2006, at 3:15 PM, during an interview, Staff B stated, "Patient A returned from dialysis and was placed in bed per Patient A's request because of being tired. At 2:10 PM, Patient A was restless and was climbing out of bed. Patient A said 'no, I don't want to get up, just hungry'. I went to dietary. Kitchen checked her diet card and gave me yogurt, cottage cheese, and a fruit plate. I opened the yogurt, opened the cottage cheese and chopped fruit with whole grapes. She eats fast. Before I left, I said slow down, eat your food slowly. I had to leave to go answer call lights."

On August 8, 2006, at 2:45 PM, during an interview, Staff M stated that on August 4, 2006, when Patient A's call light came on, staff immediately entered Patient A's room and noted Patient A's full mouth. "I said 'spit it out' after I noticed Patient A had difficulty chewing. I got the charge nurse. Licensed Nurse J, (LNJ), came in. LN J assessed that Patient A had seizure activity. For about one and a half minutes, there was jerking, eyes rolled back in Patient A's head. This progressed to a code, (emergency alert to respond to a life threatening situation), 911 was called immediately, and CPR was performed. The EMT, (Emergency Medical Technicians), arrived and Patient A was transferred to the Emergency Room."

On August 11, 2006, at 1:35 PM, review of the facility's Mechanical (Dental Soft) Diet list of "Foods to Avoid" included fresh whole fruits, berries, cherries, olives, and raisins. Patient A had been served grapes.

On October 6, 2006, Patient A's acute facility discharge records were reviewed. Per the record, Patient A arrived at the emergency room on August 4, 2006 at 3:09 PM, and was seen at 3:16 PM. Patient A was intubated, (a tube inserted into the trachea to assist breathing), unable to speak, with pinpoint non-reacting pupils. She was post cardiac arrest, possibly secondary to aspiration as it occurred while she was said to be eating (unwitnessed.) The EMT who responded to the 911 emergency call described her as being pulseless without breath sounds. He intubated her and found she had ambiguous breath sounds. After attempting to reintubate her, a grape and large amount of mucous were found in the ET tube and it was again replaced, this time with good breath sounds. Patient A was admitted to the acute care facility and death was pronounced at 0950 on August 11, 2006.

The facility failed to follow their care plan for dining assistance when no staff was available for cueing to ensure slow rate of intake, small bites, oral clearing before next bite, offering sips of liquids between bites, and ensuring chin tuck with upgraded liquids, and failed to provide the proper therapeutic diet per physician order.

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 was a direct proximate cause of the death of the patient.