Glenwood Gardens SNF
Citation Number: 120005216
Citation Date: 7/17/2008
Violation Date: 12/16/2006
Class: AA
Penalty: $ 100000.0

7231(a)(1)(A)(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: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's 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. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time - limited.

On May 30, 2007 at 4:50 PM, an unannounced visit was made to investigate an allegation that a patient choked and subsequently died after swallowing a ketchup packet.

Based on interview and record review, the facility failed to provide continuing assessment and formulate an effective plan of care for one patient (Patient 1) who had poor safety awareness and a behavior of placing objects in his mouth, which resulted in the aspiration of a foreign object and subsequent death on December 16, 2006.

The clinical record for Patient 1 was reviewed on October 5, 2007 at 1 PM. The patient was an 84 year old male admitted to the facility on October 24, 2001. He had medical diagnoses of Dementia and Chronic Obstructive Pulmonary Disease. The October 9, 2006 Minimum Data Set (MDS) documented the patient with short and long term memory impairment and poor decision making ability. The MDS also documented Patient 1 wandered daily and was socially inappropriate. The October 10, 2006 Resident Assessment Protocol (RAP) summary documented, "...Behavior trigger for being socially inappropriate m/b [manifested by] rummaged through others belongings. He also wanders inappropriately around facility. He moves w/ [with] no rational purpose oblivious to rules, safety or cautions. These triggers happen almost daily..." His diet order for December 2006 was a pureed consistency diet.

Review of the care plans was conducted during a review of the patient's clinical record on October 5, 2007 at 1 PM. An "Activities Care Plan" dated July 11, 2006 read, "Needs supervision... (Patient 1) will eat non eatable (sic) items." The goal indicated the patient will participate in activities three times per week "...without getting into non-eatable (sic) items." The approach plan included: remove table decoration for group activities, offer snacks if resident states he is hungry and offer sensory stimulating items for stimulation and pleasure. There was no other plan of care which addressed this behavior of patient placing non edible items in his mouth and appropriate interventions to be implemented by nursing. An annual activities progress note for October 11, 2006 documented the patient continues to need supervision due to the patient's tendency to eat non-edible items. The activity progress note indicated the goal would continue. A nursing note dated October 15, 2006 documented the patient was noted "with frequent episodes of grabbing staff (and) anything possible to be grabbed (without) safety awareness..." A nursing note dated October 18, 2006 documented the patient was up in his wheelchair, wandering and was observed grabbing his peers, staff and "anything that comes in his way..." A nursing note dated October 25, 2006 documented the patient continues to wander around and "taking things that he comes across".

A further review of the patient's clinical record was conducted. A nurse's note dated December 16, 2006 at 5:45 AM, documented "Patient 1 in bed in a high fowler's position, pale looking with breathing difficulty and irregular, oxygen saturation [the amount of oxygen present in the blood] at 47 percent, blood pressure - 90/64, apical pulse - 70 beats per minute" and oxygen was applied at 2 liters per minute via nasal cannula. At 6:15 AM, another nurse's note indicated the oxygen was now at 5 liters per minute via nasal cannula and suctioning was performed once. Patient 1's color was now pink with the oxygen saturation at 82 percent, pulse - 99 beats per minute and the patient answered to his name. At 12 PM, a nurse's note indicated the patient's temperature - 96.5 Fahrenheit, pulse - 86 beats per minute, respiration - 20 breaths per minute, blood pressure - 121/81. Patient 1 is responsive to touch only, continues on oxygen at 5 liters per minute, the head of the bed is elevated and the oxygen saturations is between 87 and 92 percent, suctioning performed twice for secretions in his throat for comfort and family at bedside. At 2:45 PM, the nurse documented the patient was responsive to tactile stimuli with oxygen at 5 liters minute, the head of bed elevated between 60 and 90 degrees, breathing is labored, oxygen saturation at 82 percent, pulse rate - 96 beats per minute. Suctioning was performed and it was described as "pinkish Red (sic)". At 5 PM, the nurse documented the patient was unresponsive with labored breathing, oxygen applied at 5 liters per minute, "noted gurgly sound", suctioning performed once with pinkish red secretions. At 5:30 PM, the nurse's note indicated family stated the patient was in a lot of pain, restless and uncomfortable. The physician was notified and the physician ordered Ativan (anti anxiety medication) and Morphine Sulfate (pain medication). At 6:30 PM, the nurse was called to the room by the certified nursing assistant and the patient was observed to be coughing up from a minimum to a moderate amount of blood. Family had suctioned him once and the oxygen saturation had dropped to 46 percent. Patient 1 became pale and cyanotic, remains on oxygen, head of the elevated at 90 degrees, resident unresponsive, no blood pressure, periods of apnea, and breathing slow. At 6:45 PM, the patient was unresponsive, no pulse, no blood pressure, and breathing had stopped, family at bedside.

During an interview with Family Member 1, on May 30, 2007 at 4:26 PM, she indicated Patient 1 had a history of placing things in his mouth and she had instructed the staff not to leave anything out. On one occasion, she went to visit Patient 1 and he was "sucking the shaving cream can". She indicated the patient died of a "ketchup packet" lodged in his throat, which was discovered by the Mortuary staff.

During an interview with the Kitchen Manager (KM) on October 5, 2007 at 12:58 PM, she indicated, "He (Patient 1) was very oral, even if table decorations had loose parts he would pick it up and put it in his mouth. I remember one time in particular where there were table decorations and it took several people to get it out of his mouth..."

During an interview with Certified Nursing Assistant 1 (CNA 1) on October 5, 2007 at 1:15 PM, she stated, Patient 1 wandered in other patient rooms and "he would get stuff off tables (sic)... I did caught (sic) him eating paper..." CNA 1 indicated this was the only incident she could recall where the patient placed non-edible items in his mouth.

During an interview with the Activity Director (AD), on October 5, 2007 at 1:40 PM, she indicated whenever Patient 1 was taken to activities, "we had to make sure he wouldn't eat anything". He would even take table decorations off of the table and eat them. The AD stated, "I always made sure he had snacks, so he would be eating food and not an object."

During an interview with the KM, on October 17, 2007 at 8:15 AM, she indicated ketchup packets are no longer available for patient use but there are some available for staff use. She indicated, "They faded out because (patients) couldn't open them." There was no documented evidence when the ketchup packets had been discontinued. The menu for December 15, 2006 included seasoned beef and cheese on a bun, French fries, mixed green salad with house dressing and sliced oranges.

The coroner's investigative summary, was reviewed on October 17, 2007 at 5 PM. The summary read in part, "At 0100 hours on December 19, 2006, (Mortuary embalmer) contacted this office to report her discovery of a 1 1/2 inch by 2 1/2 inch packet of...tomato catsup wedged in the back of the throat of this descendent, whom she identified as eighty-four year old (Patient 1)..." The summary also indicates the 'Tomato catsup packages like that found in the (Patient 1's) throat were available in the facility. The decedent was a long-term resident in the facility and suffered from dementia. He was also known as a "wanderer," who was often found in other resident's room and rummaging through other peoples (sic) belongings. He was also described as being very "oral," in that he was constantly putting things in his mouth...." The summary concluded the type of death was "Accident/Aspiration of foreign body."

Therefore the facility failed to provide continuing assessment and formulate a plan of care for one resident which resulted in the resident aspirating on a ketchup packet.

The above violations presented either imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result and was a direct proximate cause of the death of the patient.