CLASS AA CITATION -- PATIENT CARE
§ 483.25 Quality of Care
Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.
§483.25 (h) Accidents.
The facility must ensure that-
(1) The resident environment remains as free from accident hazards as is possible; and
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.
§483.25(a) Activities of daily living. Based on the comprehensive assessment of a
resident, the facility must ensure that-
(1) A resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that diminution was unavoidable. This includes the residents' ability to-
(2) A resident is given the appropriate treatment and services to maintain or improve his or her abilities specified in paragraph (a) (1) of this section; and
(3) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.
§483.20 Resident Assessment.
The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity.
§483.20(b) Comprehensive Assessment--(1) Resident Assessment Instrument. A
facility must make a comprehensive assessment of a resident's needs, using the
resident assessment instrument (RAI) specified by the State. The assessment must
include at least the following:
(xi) Dental and nutritional status. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts.
§483.20(d) Use. A facility must ... use the results of the assessment to develop, review and revise the resident's comprehensive plan of care.
§ 483.20(k) (1) Comprehensive Care plans.
The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the following:
(i)The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.25; and
(ii) Any services that would otherwise be required under§ 483.25 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under § 483.10 (b) (4).
(3) The services provided or arranged by the facility must
( i) Meet professional standards of quality; and
(ii) Be provided or arranged by qualified persons in accordance with each resident's written plan of care.
The Department received a complaint on July 2, 2014, alleging a resident (Resident 1) was eating a hot dog and stopped breathing and turned blue, 911 was called and the resident was transferred to a general acute care hospital (GACH) and later expired.
On 7/2/14, at 2:15 p.m., an unannounced complaint investigation was conducted.
The facility failed to provide Resident 1 with the necessary care and services to attain or maintain the highest practicable physical, mental, psychosocial well-being including, but not limited to:
1. Failure to provide a diet that Resident 1 could eat and chew without difficulty, as
stipulated in the resident's plan of care.
2. Failure to provide Resident 1 with adequate supervision during dining.
3. Failure to call 911 immediately (delay of six minutes) after Resident 1 started choking.
The facility failed to perform a comprehensive assessment of Resident 1 's needs, including but not limited to appropriate dental, nutritional, eating behavior and choking risk assessments. The facility failed to use the results of Resident 1's assessments to develop, review, and revise her plan of care to include appropriate measures to prevent choking on food. The facility also failed to provide residents with emergency response services, including immediately calling 911 upon observing residents choking, in accordance with professional standards of quality.
Resident 1 was transferred to a general acute care hospital (GACH) and expired approximately one hour later from respiratory failure.
A review of Resident 1's Admission Record indicated the resident was a 76 year-old female who was readmitted to the facility on 4/29/13. The resident's diagnoses included obesity, muscle weakness, Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow imprecise movements), and schizophrenia (a psychotic disorder marked by severely impaired thinking, emotions, and behaviors).
A review of a Minimum Data Set (MDS), an assessment and care screening tool, dated 9/22/13, indicated Resident 1 was usually able to make herself understood and understand others. The resident required supervision with eating, and limited assistance, with a one-person physical assist in bed mobility, transferring, dressing, and toilet use. Resident 1 weighed 236 pounds and used a wheelchair to get around the facility.
Another MDS assessment, dated 4/1/14, under Section L: Oral/Dental Status, indicated the resident had no problems with her teeth or difficulty in chewing, which is contrary to the dental assessments, dated 9/12/13, 11/12/13, 11/19/13,1/31/14 and 2/27/14. According to the dental assessments, Resident 1 had 16 missing teeth and three broken teeth, requiring extraction.
On 7/2/14 at 2:45p.m., during a telephone interview, the certified nursing assistant (CNA 1), who was assigned to pass dinner trays and provide supervision during meals, stated on 4/22/14 at approximately 4:30p.m., he and another CNA (CNA 2) were in the dining room passing out dinner trays and coffee. CNA 1 stated the dinner included hot dogs. CNA1 stated Resident 1's hot dog was not cut up into small pieces and the resident had the tendency to eat fast. CNA 1 stated that around 4:45 p.m., while he was passing out coffee, CNA 2 called his name and stated Resident 1 was choking. CNA 1 stated as he turned around, he saw Resident 1 with both hands on her neck, unable to speak, and her face was blue. CNA 1 stated Resident 1 was sitting in her wheelchair, so he went behind the wheelchair and attempted to put his hands around Resident 1 to perform an abdominal thrust (an emergency technique when a person's airway [windpipe] becomes blocked with food or other objects). CNA 1 stated he asked Resident 1 to stand up, but the resident did not respond. He stated that he and CNA 2 could not get Resident 1 out of the wheelchair and stand her up because she was too heavy. CNA 1 stated he performed the abdominal thrusts while Resident 1 was sitting in the wheelchair for about three minutes and the resident passed out. CNA 1 stated after Resident 1 passed out, a licensed vocational nurse (LVN 1) entered the dining room and instructed him to lay Resident 1 on the floor to initiate cardiopulmonary resuscitation ([CPR], an emergency procedure used during cardiac and/or respiratory arrest to stimulate the heart and provide artificial breathing to maintain circulation of oxygen rich blood to the brain).
On 7/2/14 at 3:15 p.m., during an interview, CNA 2 stated Resident 1 had missing teeth and did not have any dentures. CNA 2 stated on 4/22/14 between the hours of 4:30 to 5 p.m., she and CNA 1 were passing out dinner trays, which consisted of hot dogs. CNA 2 stated Resident 1's hot dog was placed inside a bun and the hot dog was not cut up into small pieces. CNA 2 stated a male resident called out, "The patient is choking!" CNA 2 stated CNA 1 stood behind the wheelchair then put his arms around Resident 1 with his arms under Resident 1's chest in an attempt to do abdominal thrusts. CNA 2 stated CNA 1 attempted the abdominal thrusts several times, but they were not effective, because CNA 1 could not completely put his arms around the resident's body. CNA 2 stated when LVN 1 arrived in the dining room they (all three) put Resident 1 on the floor.
A review of the facility's undated policy and procedures titled, "Heimlich Maneuver" indicated to do the following:
1. If a person is choking on food or a foreign body and was unable to speak or make any
sounds, act immediately.
2. Call out for help.
3. Stand behind the resident and wrap arms around the waist, make a fist, grab it with your other hand and place thumb side of fist against resident's abdominal area above the navel and below xiphoid process (the lower part of the breastbone). Press inward and upward with quick thrust. The policy further indicated to perform the Heimlich maneuver on a resident lying down or unconscious, roll the resident onto his/her back then kneel and straddle his/her hips. Place one hand on top of the other then place both hands on the resident's abdomen above the navel and below xiphoid process. Press inward and upward with six to eight quick thrusts. Move the resident's head (to the side) and look in the mouth for objects, remove it. If unconscious, attempt to ventilate. If unable to ventilate, repeat (the process of abdominal thrust).
An article by the Red Cross titled," Conscious Choking," indicated if a victim is unable to
cough, speak, or breathe, someone should call 911 immediately first before back blows
or the Heimlich interventions are implemented
On 7/2/14 at 3:30 p.m., during an interview, LVN 1 stated a staff informed her that the resident was choking in the dining room. LVN 1 stated when she arrived in the dining room she saw CNA 1 attempting the Heimlich maneuver while Resident 1 was sitting in her wheelchair, but nothing was coming out of the resident's mouth. LVN 1 stated she assisted the CNAs to lay Resident 1 on the floor. LVN 1 stated CNA 1 positioned the resident's face to the right side in case any food came out of her mouth. LVN 1 stated CNA 1 then knelt beside Resident 1,(not in a straddle position, as per the facility's policy and the standard of practice), to continue with abdominal thrusts. LVN 1 stated after a minute of abdominal thrusts, while Resident 1 was lying on the floor, a piece of un-chewed hot dog, approximately an inch in length came out. LVN 1 stated she used her finger to sweep the piece of hot dog out of the resident's mouth. LVN 1 stated after the piece of hot dog came out, the resident took a deep breath and then the resident stopped breathing.
LVN 1 stated the director of nursing (DON) entered the dining room and called 911, and she and CNA 1 initiated CPR. LVN 1 stated the paramedics arrived within five minutes from the time the DON initiated the 911 call. LVN 1 stated Resident 1 choked on the hot dog because the resident was eating too fast and the staff would have to remind the resident to slow down while eating. When LVN 1 was asked why Resident 1 ··s hot dog was not cut up, when the resident had missing teeth, and was known to eat fast, LVN 1 stated, "I am not her nurse so I don't know."
On 7/2/14 at 4 p.m., during an interview, the director of nurses (DON), stated on 4/22/14 between the hours of 4:30 to 4:45p.m., a staff member told her Resident 1 was choking. The DON stated when she arrived to the dining room, she saw Resident 1 lying on the floor unconscious. The DON stated she called 911, which was six minutes after the resident started choking according to the paramedic's report, and got an Ambu bag (a self-inflating bag, a hand-held device commonly used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately) to bag (provide rescue breathing) Resident 1 while CNA 1 was doing chest compressions. The DON stated the paramedics arrived within five minutes after she called 911.
On 7/2/14 at 5 p.m., during an interview, LVN 2 stated Resident 1 had a history of eating fast. LVN 2 stated if the staff did not slow the resident down while eating, the resident would finish the whole plate in less than two minutes. LVN 2 stated whenever the staff prompted Resident 1 to slow down during meal time, the resident would slow down for a couple of minutes and then would start eating fast again. LVN 2 stated he was not sure if Resident 1's eating habit had been discussed during the interdisciplinary team (IDT) meeting because he did not attend the meetings. (An IDT meeting consists of the heads of the different disciplines who work together to discuss a resident's care). LVN 2 stated he was not sure if a care plan had been developed to address the resident's risk of choking due to eating fast.
A review of a dental care progress note, dated 9/12/13, indicated the resident was partially edentulous (no teeth), with several broken teeth, but the resident did not want to wear dentures. A review of another dental note, dated 11/19/13, indicated Resident 1 had 16 missing teeth, plus three broken teeth (normal amount= 36 teeth).
A review of Resident 1's IDT meeting notes, dated 1/7/14 and 4/7/14, indicated there was no documented evidence the IDT team addressed or discussed the resident's risk for choking due to being partially edentulous and having a habit of eating fast.
On 7/2/14 at 5:10p.m., a review of Resident 1's medical record with the DON indicated there was no risk assessment for choking or a care plan developed to address Resident 1 's habit of eating fast and being partially edentulous, placing the resident at increased risk of choking.
However, there was a plan of care, titled, "Dental Care," dated 5/1/13, indicating the resident had some natural teeth and did not use dentures. The goal was for the resident to chew, eat and drink without pain. The staff's approaches included to provide food which the resident could chew and swallow without difficulty.
On 10/9/14 at 11:50 a.m., during a telephone interview, the facility's registered dietitian (RD) was questioned regarding Resident 1 rece iving a regular non-chopped diet in light of the resident's missing teeth. The RD stated according to her dietary assessment, Resident 1 had some missing front top and bottom teeth, but the molars were still present for chewing. The RD stated she could remember the resident had approximately four missing teeth, but she was not 100 percent(%) sure. The RD stated she was also aware of the resident's behavior of eating fast, but the behavior itself would not necessitate changing the resident's diet.
During a subsequent telephone interview with the RD, on 10/9/14, at 2:55p.m., the RD was informed of the resident's dental status, including the amount of missing teeth, per the dental consult. The RD stated she was not aware Resident 1 was missing that many teeth, including molars (teeth used to chew food/grinding teeth at the back of the mouth).
On 10/9/14 at 12:40 p.m., during a telephone interview, the resident's dentist stated according to the dental notes, dated 11 /19/13, Resident 1 had 16 missing teeth , plus three root tips (broken teeth in which only the root of these teeth were present). The dentist stated each human has 32 teeth (16 on the upper and 16 on the lower jaw). The dentist stated the resident's teeth Numbers 1, 3, 7, 8, 9, 12, 15, 16, 17, 18, 19, 24, 25, 26, 31, and 32 were missing and for Numbers 2, 12, and 29, only the roots were present.
A review of the physician's order for Resident 1's diet, dated 2/14/14, indicated a regular small portion, no gravy, and non-fat milk diet.
On 10/9/14 at 2:30p.m., during an interview, the DON stated she was aware Resident 1 had some missing teeth, but she did not know the exact count. The DON stated if she had known Resident 1 had that many missing teeth, she would have developed a nursing care plan for risk of choking with interventions which included to observe and monitor the resident during meal time, prompt the resident to slow down during eating, make sure the resident was able to tolerate her diet, and discuss with the physician if there was any concern or change in condition. When asked if Resident 1 's physician was aware of the resident's dental status, the DON stated, "I never told the doctor, but the record was available for all staff and the physician to review. " On 10/9/14 at 3:05p.m., during an interview, CNA 1 stated he inspected Resident's hotdog on her dinner tray and noted there were two pieces bitten off from the resident's hotdog. CNA 1 stated when the paramedics arrived; they used the machine
(defibrill ator, a machine used to control heart fibrillation by application of an electric current to the chest wall or heart) to shock the resident. On 3/27/15 at 4:30p.m., during a telephone interview, Resident 1's physician stated he did not know the resident had 16 missing teeth and three broken teeth. The physician stated the nurses did not report to him any issue regarding the resident's eating behaviors. The physician stated if the nurse had informed him about the resident's dental status, he would have changed Resident 1 's diet from regular to a mechanical soft (food made easier to chew and swallow) with ground meat. A review of an Emergency Medical Services (EMS) Report, dated 4/22/14, indicated the emergency response unit was dispatched at 4:51 p.m., six minutes after Resident 1 started to choke on the hot dog, and arrived at 4:56p.m., and saw the resident at 4:57 p.m. The report indicated Resident 1 was found lying on the ground unconscious and unresponsive. Two large pieces of food was removed with a McGill forceps (an angled forceps) with copious (large) amount of vomit. After removal of the food particles, there was no change in the resident's status. According to the EMS report, advanced cardiac -. life support ([ACLS], clinical interventions for an urgent treatment of cardiac arrest) was started at 4:59 p.m. The paramedics transferred Resident 1 to the GACH at 5:12 p.m. A review of the GACH's emergency room report, dated 4/22/14, indicated Resident 1 arrived at 5:27 p.m. and was unresponsive in full cardiac arrest (cardiopulmonary arrest) upon arrival. According to the report, Resident 1 was pronounced deceased at 5:40 p.m. A review of Resident 1 's death certificate, dated 5/8/14, indicated the resident's immediate cause of death was respiratory failure (not enough oxygen into the lungs). The facility failed to provide Resident 1 with the necessary care and services to attain or maintain the highest practicable physical, mental, psychosocial well-being including, but not limited to: 1. Providing a diet which Resident ·1 could eat and chew without difficulty, as stipulated in the resident's plan of care.
2. Providing Resident 1 with adequate supervision during dining. 3. Calling 911 immediately (delay of six minutes) after Resident 1 started choking. The facility failed to perform a comprehensive assessment of Resident 1 's needs, including but not limited to appropriate dental, nutritional, eating behavior and choking risk assessments. The f~cility failed to use the results of Resident 1 's assessments to develop, review, and revise her plan of care to include appropriate measures to prevent choking on food. The facility also failed to provide residents with emergency response services, including immediately calling 911 on first observing Resident 1 choking, in accordance with professional standards of quality. The above violation presented either imminent danger that death or serious harm would resu lt or a substantial probability that death or serious physical harm would result and was a direct proximate cause of death for Resident 1. NOTE: