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
Complaint(s): CA00183466, CA00183154, CA00182739
I A 136 DIV5 CH3 ART3-72301 (f) Required Service
(f) The facility shall ensure that all orders, written by a person lawfully authorized to prescribe, shall be carried out unless contraindicated,
The violation of this regulation is written under A-164,
A 164 T22 DIV5 CH3 ART3-72311(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.
Based on interview and record review, the facility failed to ensure that a physician's order and care plan for a prescribed diet that included a texture modification was followed for Patient A. On 3/24/09, Patient A choked on a sandwich, aspirated, developed pneumonia, and died five days later of aspiration pneumonia and respiratory failure.
Patient A was an -- who was admitted to the facility on --, with diagnoses that included Alzheimer's, high blood pressure, anxiety, and generalized pain.
Patient A's record contained a physician order, dated 9/25/09, for a "Regular Diet," with the consistency: "Grind," (food from the regular diet where the texture of the food has been modified. Meats, fruits, and vegetables are ground up to minimize difficulties for patients who have chewing or swallowing problems).
On 10/8/08, the facility completed a comprehensive· assessment of Patient A using the Minimum Data Set (MDS -an assessment tool). The facility assessed that Patient A had "some/all natural "teeth lost -does not have or use dentures (or partial : plates)," that -- had a "chewing problem," and had a "mechanically altered diet."
The facility developed a care plan for Patient A that· indicated -- had a "Potential for alteration in nutrition/hydration status." The care plan I approaches included #1. Grind diet and #2. Supervise eating.
On 1/24/09, Patient A had a dental exam. The· . examiner noted "...Patient only has two remaining' teeth..."
On 6/2/09 at 11:45 pm, Staff 3 was interviewed. : She stated that on the night of 3/23/09, at shift i change (from the evening shift to the night shift), Patient A was awake, up, and moving around. Staff I 3 stated that if patients were up, staff would take' them to the actiVity room. She stated that since Patient A was still awake -- had been taken to the activity room and had been placed in a geri chair (a ! large padded adjustable recliner) with a table, and i had been given an actiVity to do. Staff 3 stated Staff 2 was in the actiVity room with Patient A and two other patients, who were also awake that night.
Staff 3 stated that she knew that when Patient A I was given food -- would calm down. She stated she went to the nurse's station where there were containers of apple sauce and pudding. Staff 3 stated that she knew that would not be enough food ! to satisfy Patient A, so she went to the front nurse's station where she found a "meat and cheese" sandwich. She stated she took the sandwich, gave it to Patient A, and then went to check on the other patients down the hall. She stated that Staff 2 continued to watch the three patients in the activity room. Staff 3 stated she knew Patient A was on a regular diet but she was not aware of the texture restriction of "grind."
On 6/2/09 at 3:30 pm, Staff 2 was interviewed and described the following event.
On 3/24/09, just after midnight, Patient A was still • awake so -- was in the actiVity room in a geri chair with a table. Staff 2 was in the activity room with Patient A. She stated the only thing that was on , the table was the plate from the sandwich that Patient A had been given by Staff 3. She stated she looked at Patient A to check on --, -- had -- hands to -- throat. She went over to -- put the table down, and Patient A stood up by -- . Staff 2 tried again to get behind: Staff 3 came into the room and then went to get Staff 1. Staff 2 stated she had performed the Heimlich maneuver (a technique used to assist choking victims) several times by the time Staff 1 arrived. She stated Staff 1 and Staff 3 took over and performed the Heimlich maneuver. Staff 2 stated Patient A went limp, that -- was placed -- on -- side, and chests thrusts were administered.: She further stated that they transferred Patient A to a chair and performed the Heimlich maneuver again. Staff 2 stated that some "stuff' came up which she described as a "bread white" material.
Staff 2 stated that another staff member had called 911.
The "Prehospital Run Report," dated -- from the local emergency responders, documented that the 911 call was received at 31 minutes after midnight. They were enroute three minutes later, arrived at the facility at 38 minutes after midnight, and had their first contact with Patient A at 40 : minutes after midnight.
The first responders documented that Patient A was unresponsive and lying supine on the floor. -- was pink in color, had warm dry skin, equal pupils, regular pulse in a sinus tachycardiac rhythm, and had labored respirations without air movement. They further documented: "...Airway is obstructed by large pieces of meat from a sandwich with little or no air movement. Pt (patient) has JVD Gugular venous distention), and accessory muscle use with each respiration, absent lung sounds in all fields, .."
The first responders suctioned Patient A and a "partial removal of airway obstruction. using forceps, The first responders provided! "Ventilation with BVM (bag valve mask) and (oxygen at 15 liters per minute). Pt (patient) was intubated..."
On 3/24/09 at 1:07 am, Patient A was transferred from the facility, by ambulance, to an acute care hospital.
The Emergency Room Record documented Patient· A's "Chief Complaint: Respiratory arrest after choking while eating a sandwich." Upon arrival in the emergency room -- had spontaneous respirations although was not completely alert.
On 3/29109 at 5:55 pm, five days later, Patient A. · died. The Death Certificate documented that the cause of death was from, aspiration pneumonia, , respiratory failure, and dementia Alzheimer's type.
Therefore, the facility failed to follow the physician's ! order for a prescribed diet, and failed to follow the care plan for a diet texture modification for Patient Patient A choked on the sandwich, aspirated, developed pneumonia, and died five days later of aspiration pneumonia and respiratory failure.
These failures presented either imminent danger. that death or serious harm would result or a substantial probability that death or : physical harm would result and was . proximate cause of the death of the patient.