Loretto Health and Rehabilitation Center

Deficiency Details, Complaint Survey, October 3, 2012

PFI: 0648
Regional Office: Central New York Regional Office

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F323 483.25(h): FACILITY IS FREE OF ACCIDENT HAZARDS

Scope: Pattern

Severity: Immediate Jeopardy

Substandard Quality of Care

Corrected Date: December 14, 2012

The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.

Citation date: October 3, 2012

Based on observation, record review and staff interviews conducted during the partial extended survey (#NY00120863), it was determined for 6 of 6 residents (Residents #1,2,3,4, 5 and 6) reviewed for accident hazards, the facility did not consistently provide an environment free of hazards, and did not provide adequate supervision to prevent accidents. Specifically, for Resident #1, the facility failed to develop and implement a safe feeding plan for a resident identified with swallowing difficulties. Additionally, when the resident was found unresponsive in the dining room, the facility failed to implement emergency measures in a timely manner. For Residents #2, 3, 4, 5 and 6, the facility failed to maintain updated feeding plans, and implement the feeding plans for these residents who were identified on aspiration precautions. This resulted in actual harm for Resident #1 and no actual harm with the potential for more than minimal harm that resulted in immediate jeopardy and substandard quality of care for Residents #2, 3, 4, 5 and 6. Findings include:

1) Resident #1 was admitted to the facility on July 16, 2012 following a surgical repair of a left hip fracture (July 8, 2012). The resident's ongoing diagnoses include dementia Alzheimer's type, chronic obstructive pulmonary disease (COPD - lung disease), and a history of pneumonia.

FAILURE TO DEVELOP AND IMPLEMENT A SAFE FEEDING PLAN

The following information was provided to the facility on admission from the discharging hospital:

- The History and Physical Exam Report completed at the hospital on July 7, 2012 documented the resident was admitted to the hospital following a fall.

- The Operative/Procedure Report dated July 8, 2012 documented the resident had a left intertrochanteric fracture and an open reduction and internal fixation (ORIF) procedure was performed. The postoperative plan was for "cautious fluid administration."

- A Clinical Swallow Evaluation completed on July 10, 2012 documented the resident was on a regular diet prior to hospitalization, with no history of dysphagia per the resident's "children." The resident had not had any oral intake since admission. The speech therapist documented the resident tolerated nectar thick liquids and "puree trials resulted in oral holding" with the need for verbal cues to swallow. The resident needed additional verbal cues to clear residue after swallowing. The resident was not able to tolerate the trial of puree food and the resulting recommendation included "nectar thick liquids only", aspiration precautions and total assistance with oral intake. A follow up with the communication disorder unit was to occur the following day (July 11, 2012) to monitor tolerance and "ADAT" (advance diet as tolerated). The follow up evaluation was not included in the documentation provided to the facility at the time of admission or during the resident's stay.

- The eKardex Report (electronic record for medication administration) documented on July 11, 2012, the resident's diet was a regular adult diet with nectar thick liquids and Ensure Plus.

- On July 13, 2012 the Loretto System Assessment, completed by the Loretto "screener" at the discharging hospital, was faxed to Loretto. The "Confidence Sheet" related to Nutrition documented: diet as regular, nectar thick liquids; aspiration precautions, and "diff (difficulty) swallowing pills. The form did not identify any chewing or swallowing problem and did not document the resident had an SLP (speech language pathologist) evaluation.

- The hospital Discharge and Referral Orders dated July 16, 2012 documented the resident's diet as "nectar thick liquid, soft foods."

- The hospital Discharge Summary, dictated on July 16, 2012 at 12:57 PM, was faxed to the facility at 4:03 PM on July 16, 2012 . The summary included a diagnosis of oropharyngeal dysphagia and documented "during the weekend prior to discharge" the resident was able to tolerate good oral intake and was "switched to a pureed diet with honey thick liquids." The discharge disposition was documented as "improved" and to discharge the resident on a "pureed thickened liquid diet."

At 3:30 PM on July 16, 2012, the diet technician documented in a progress note the resident was admitted from the hospital and had no chewing/swallowing difficulty "per transfer paperwork" and the resident's diet order on admission was "regular unmodified" with nectar thick liquids.

The New Admission Physician Orders dated July 16, 2012 and signed by the NP had the diet printed by hand (in a different writing than the orders) as regular, unmodified with nectar thick liquids.

The NP's "Admitting Note" dated July 16, 2012 documented the resident had a clinical swallow evaluation on July 10, 2012 "which recommended nectar thickened liquids with pureed trials resulting in her oral holding and the need for verbal cues to swallow." The resident was on aspiration precautions, and needed assistance with her oral intake. The NP's assessment and plan documented "her diet will be soft with nectar-thickened liquids" and documented she would wait for the dietitian to review the resident's swallowing evaluation.

The NP was interviewed on October 1, 2012 at 2:40 PM and she stated her normal procedure following a resident's admission was to review all the information that accompanied the resident from the discharging facility. She said the discharge summary did not always come with the resident and sometimes came following the resident's admission. The NP stated her routine was to communicate with dietary and write a diet order based on the recommendation from dietary. She stated staff would not see her admission note on the day of admission as she dictated the note and it did not return to the unit on the same date. When questioned about a soft diet (per her note) and the order for an unmodified diet, the NP stated they were similar. She stated it was not the facility practice to write orders for aspiration precautions and this information would be based on the resident's comprehensive care plan (CCP). She stated if the resident was on aspiration precautions, she would have expected the resident to be seated at a table where staff were going to feed her. The NP did not include the diagnoses of dysphagia on her admission diagnoses list and when questioned, stated she did not know why it was not included and thought she just missed it when dictating her note.

The diet technician who wrote the admitting dietary note was interviewed on October 2, 2012 between 4:00 PM and 4:30 PM. She stated her procedure was to gather the information on the day of admission, prior to 4 PM, when the diet needed to be called down to the kitchen. To gather this information, she visited the resident, talked to family (if present) and reviewed the information from the discharge facility. She said she reviewed "all paperwork" available, including, for example: the screen (from Loretto screener), lab work, medications, hospital admission information, skin condition, swallow evaluation (if provided), and review for a history of falls, skin tears, and diagnosis of dysphagia. She stated anything with discharge information was the most important. As she did not recall the situation with Resident #1, the surveyor asked her to review the hospital discharge information and explain what diet she would have recommended based on the information provided. (the hospital discharge summary was not provided to her as it was faxed to the facility after the diet technician wrote her admission note). Upon reviewing the information, she stated she would use the information from the swallowing evaluation and referred the surveyor to the portion of the evaluation that documented "current diet - regular" and nectar thick liquids. She stated the swallow evaluation did not say anything about pureed or ground food and thought the evaluation was "inadequate." Upon seeing the Kardex orders for July 11, 2012, she stated she would have possibly used that information and recommended the regular diet with nectar thick liquids. She stated, if she saw the discharge order for the soft diet with nectar thick liquids, she would have recommended that diet, and had she seen the discharge summary, she would have recommended the pureed diet with honey thick liquids. She stated, if the discharge summary arrived after the resident and after she reviewed the hospital information, nursing would inform her of the additional information, and she would review it at that time. She did not know if she was ever made aware of Resident #1's discharge summary.

For this resident who arrived with conflicting information related to her diet consistency from the discharging provider, the facility did not clarify the information upon admission, prior to writing the diet order.

FAILURE TO PROVIDE EMERGENCY MEASURES

Review of the facility menu for the evening meal on July 17, 2012 revealed the entree was kielbasa.

On July 17, 2012 the licensed practical nurse (LPN) documented in a progress note the resident was "noted to be unresponsive after supper." The supervisor was called and the resident was "put to bed." The supervisor assessed the resident.

The LPN was interviewed on October 1, 2012 at 5:50 PM. She stated she started her July 17, 2012 shift on the unit at 3 PM. She recalled the following from July 17, 2012:
- The resident was with her family member, complained of pain, and Lortab "I think" was given to the resident " about 4 PM;
- The resident's family member brought her into the dining room and when the meal (supper) came (approximately 5:20 PM), the LPN and family member watched the resident from the hall outside the dining room (through the glass), and the resident was feeding herself;
- The family member and LPN were pleased the resident was feeding herself and the LPN stated "days" (7 to 3 shift) said they had to help her a little with her meal;
- The LPN stated the resident was seated at a long table in the front of the dining room on the right hand side and ate independently. The LPN went to the front left corner of the dining room to assist the residents who needed to be fed;
- The LPN could not recall if someone brought her attention to Resident #1 or if she just looked over and noticed she was slumped over in the chair and pale. She stated she "looked like she was already gone"
- The LPN tried to wake her up but received no response. The resident was seated with her eyes closed and "looked like she was sleeping but her color was pale"
- The LPN did a sternal rub, received no response and did not start resuscitation as she knew the resident was a DNR;
- The supervisor was called and the LPN wheeled the resident back to her room and the resident was placed in bed prior to the RN Supervisor assessing the resident;
- The LPN stated the RN checked the resident to see if there was food in her mouth when she was in bed; and
- The LPN stated the resident did not seem to be eating at the time she observed her in the dining room, as she did not have a utensil in her hand, so she did not think the resident was choking.

On July 17, 2012 the registered nurse (RN) documented in a progress note, she assessed the resident by looking to see if her air way was clear "and it was". The resident had no breath sounds, no heart sounds and the RN documented the resident expired at 6:05 PM. The medical examiner was notified as she had a recent fall with resulting surgery.

The RN Supervisor was interviewed on October 1, 2012 between 4 PM and 4:30 PM. She stated the following from her recollection of July 17, 2012:
- she received a call from Unit 6 to come to the unit for an emergency;
- the resident was being transferred to the bed when she arrived on the unit;
- she checked the resident's respiratory status and checked for lung sounds, and stated her airway was clear;
- as the resident was DNR, she did not start resuscitation and she "pronounced her."

The RN Supervisor, when interviewed on October 1, 2012 between 4 PM and 4:30 PM stated staff told her the resident had not been eating at the time they discovered her unresponsive. She stated if she had choked and was unresponsive in the dining room, she would have checked her before they moved her. Her understanding from the staff was they moved her as she was not eating, and for "dignity" they removed her from the other residents in the dining room.

The RN Supervisor was asked about aspiration precautions, when she was interviewed on October 1, 2012 between 4 PM and 4:30 PM. She stated staff (for example nurses and CNAs) would need to check to be sure the resident received the right consistency solids and fluids, and according to the facility policy, the nurse needed to watch the resident closely related to her swallowing and chewing ability. The RN stated the information regarding aspiration precautions was on the aide assignment sheet and also identified by dietary with a colored napkin.

The RN Manager was interviewed on October 2, 2012 at 9:50 AM. She stated, when a resident was a new admission, she (or the RN clinical coordinator) assessed the resident and if they thought the resident could eat independently, they would assign the person to a table near a staff person. If the resident was identified with aspiration precautions, she would seat her at a table near a "feeder table" or "where staff is sitting". She would not seat her at an "independent" table. When the RN Manager was asked about the table in the right front corner of the dining room (table identified by the LPN as where Resident #1 was seated) she said the table was for residents who were independent with need for cuing only.

The NP documented in a discharge summary, dated July 18, 2012, the resident was given hydrocodone with Tylenol at 4:30 PM on July 17, 2012 due to complaining of hip pain. "Shortly thereafter" she became diaphoretic, "complaining about some increased pain," became unresponsive and since she was a DNR (do not resuscitate), no resuscitation was attempted.

The forensic autopsy report dated July 17, 2012 documented the resident expired due to aspiration of foreign body and asphyxia. The report documented that a rectangular piece of sausage that was 2 centimeters (cm) by 1.5 cm by 1.5 cm was lodged in the larynx below the epiglottis.

The facility did not have a plan in place to monitor the resident related to aspiration precautions,and did not provide emergency treatment when found unresponsive in the dining room, at meal time.

In summary, the facility failed to develop and implement a safe feeding plan, and failed to provide emergency measures.

2) Resident #2 was admitted to the facility in May, 2009 and had diagnoses including dementia, anxiety, and pulmonary edema related to congestive heart failure.

A Speech and Language consult was requested on May 18, 2009 as a result of her pocketing (holding food within the cheeks of the mouth) food. The resident's diet was identified as ground with nectar thick liquids and thin liquids in Provale cup only (a cup used to improve independent hydration for dysphagia). The resident was unable to cooperate with the evaluation and the speech therapist requested to be contacted again if the resident developed signs and symptoms of dysphagia.

On October 21, 2009 a Speech and Language consultation was requested by the dietitian, as the resident's diet had been changed to puree related to an unresponsive episode, and the resident's status had improved since admission. The recommendations resulting from the consultation included:
- upgrade the diet to "soft solids" with thin liquids;
- aspiration precautions;
- alternate solid swallows with liquid swallow to clear lingual residue; and
- position upright at 90 degrees for meals.

A physician progress note date May 15, 2012 documented nursing requested the resident be seen as she had persistent white coating on her tongue.

On August 5, 2012, a nursing progress note documented the resident was noted to pocket food after lunch and a finger sweep was done to remove food from both inner cheeks.

The most recent physician orders dated August 8, 2012 documented the resident's diet was a regular pureed with thin liquids.

The Minimum Data Set (MDS) assessment dated September 22, 2012 documented the resident had moderate cognitive impairment for decision making, and required set up and supervision for eating. Nutritional approaches included a mechanically altered diet.

The comprehensive care plan (CCP) updated on September 25, 2012 documented the resident had the potential for aspiration related to chewing/swallowing problems including decreased lingual strength and "pockets food." The plan included "feeding strategies per SLP" (speech pathologist) and included sitting upright for all oral intake, no straws, oral care after meals, and monitor for signs and symptoms of aspiration.

On October 1, 2012 at 5:20 PM, 2 certified nurse aides (CNAs #1 and 2) on the resident's unit were interviewed regarding aspiration precautions. CNA #1 who was familiar with the unit stated information "may be on the corkboard" on the wall in the dining room, in a book.

A blue binder referred to as the "Feeding Strategies" was located in the dining room near the corkboard on Unit 6 on October 1, 2012 at 5:25 PM. The initial page in the book was labeled "Aspriation Precautions Updated List" and was dated June 27, 2011. Resident #2's name was listed and documented the resident was on a puree diet with thin liquids, alternate solids with liquids, seated upright, no straws, and oral care.

The activities of daily living (ADL) assignment sheet used by the CNAs at the time of the survey, documented the following for the resident's needs: set up, a pureed diet and "see feeding strategies book."

The resident was observed on October 1, 2012 between 5:30 PM and 5:50 PM. The resident was seated at the table in the dining room with her meal in front of her. The resident was slouched in the chair with her head and chin close to her chest. She was not observed to be assisted or supervised when eating and did not alternate solids and fluids when feeding herself.

In summary, for this resident identified to be an aspiration risk, the facility did not follow the plan of care for aspiration precautions, as identified in the comprehensive care plan, and in the blue binder (as directed in the CNA assignment sheet).

3) Resident #3 had diagnoses including a history of a cerebral vascular accident (CVA - stroke) with hemiparesis (weakness on one side of the body) and recurrent aspiration pneumonia.

Review of the resident's record revealed the resident was evaluated by speech therapy on April 30, 2007, November 13, 2007, June 24, 2010 and July 5, 2011.

The "Aspiration Precautions Updated List" located in the resident's dining room on October 1, 2012 at 5:20 PM, and dated June 27, 2011 documented the resident's plan as follows: "puree thin liquids/ small bites, single sips (straw), must attempt each bite of puree with single sip of liquids, observe for swallow after each bite/sip."

A speech therapy treatment note dated July 5, 2011 documented the resident had dysphagia, oropharyngeal phase, with onset September, 2005. A clinical swallow evaluation was completed recommending a puree diet with nectar thick liquids.

The current physician orders dated August 1, 2012 documented the diet order as regular puree with nectar thick liquids, aspiration precautions. The order for the precautions included: seat upright for meals, remain upright for 30 to 45 minutes after meals - reduce size of sips (single), alternate liquid and solids, verbal reminders to swallow, and constant supervision fed by staff.

The physician progress note dated August 1, 2012 documented the resident "has had" aspiration pneumonia and was on a "supraglottic diet."

The Minimum Data Set (MDS) assessment dated August 15, 2012 documented the resident had severe cognitive impairment and required total assistance eating. The nutritional approach identified the resident to be on a mechanically altered diet.

On August 21, 2012, the diet technician documented in a progress note, the resident was on a pureed diet with nectar thick liquids related to aspiration precautions. She documented the CNA reported the resident had no problems with chewing or swallowing food on the current diet and received a "blue napkin" ( to mean she needed thickened liquids) at meals.

The comprehensive care plan (CCP), updated on August 28, 2012 documented the resident had a potential for aspiration related to chewing/swallowing problems and was on aspiration precautions. The plan included feeding strategies per the speech language pathologist: sit upright (90 degrees) for meals, remain upright for 30 to 45 minutes after meals, reduce size of sips and half size teaspoonfuls, alternate liquids and solids, and verbal reminders to swallow.

The activities of daily living (ADL) assignment sheet used by the CNAs at the time of the survey, documented the resident required total help feeding, was on a regular pureed diet with nectar thick liquids and to "see feeding strategies book."

On October 1, 2012 at 5:15 PM CNAs #1 and 2 on Resident #3's unit were interviewed related to aspiration precautions. CNA #1 stated this unit was her usual unit and, when explaining the procedure in the dining room, stated the residents with blue napkins required encouragement eating, and the red napkins meant the resident was on thickened liquid. She hesitated and said "or maybe I have it backwards." She stated specific instructions for feeding/aspiration precautions were either found in the nursing office, or "maybe on the corkboard" and she pointed to a board in the dining room. The blue binder/book was labeled "feeding strategy book." CNA #2 did not respond to the questions and stated this was not his usual unit.

On October 1, 2012 between 5:20 PM and 5:35 PM, the resident was observed being assisted in the dining room with the evening meal. The staff member assisting the resident gave the resident a drink and the resident was observed taking several sips at once, using a straw.

The CNAs (CNAs # 2,3, and 4)who were assisting Resident #3 and the other residents at the table on October 1, 2012 between 5:30 PM and 5:50 PM were interviewed regarding assisting the residents. CNA #3 stated she "checks the strategy binder for aspiration precautions" and how the resident was to be fed. CNA #4 stated she checked the binder "usually every other day" in case there were changes and said "it changes so frequently." CNA #2 stated he did not know what residents were on aspiration precautions as he did not normally work on this unit.

In summary, for Resident #3 who was identified at risk for aspiration, the facility did not follow the plan of care as identified in the physician's orders, in the care plan and in the blue binder (as directed by the CNA assignment sheet). The blue binder was not up to date as it was dated July 2011 and identified Resident #3 on thin liquids, whereas the resident's diet was nectar thick liquids.

10 NYCRR 415.12(h)(1)(2)

F490 483.75: FACILITY ADMINISTERED EFFECTIVELY TO OBTAIN HIGHEST PRACTICABLE WELL BEING

Scope: Pattern

Severity: Immediate Jeopardy

Corrected Date: December 14, 2012

A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.

Citation date: October 3, 2012

Based on record review and staff interview conducted during the partial extended survey ( #NY00120863) , the Administrator and Director of Nursing (DON) failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain or maintain the highest practicable physical well-being of each resident. Specifically, administration failed to ensure the facility had systems in place to ensure:
- therapeutic diets were ordered by the appropriate medical practitioner;
- safe feeding plans were identified and updated for residents with swallowing difficulties;
- aspiration precautions were identified and plans implemented; and
- emergency measures were implemented in a timely manner.
This resulted in actual harm for Resident #1 with the potential for more than minimal harm that is Immediate Jeopardy to the health and safety of residents, including Residents #, 2, 3 4, 5 and 6, and residents on Units 6, 7 and 8. Refer to F281, and F323.
Findings include:

The Administrator was interviewed on October 2, 2012 at 1:30 PM. He stated he was not aware of the problems until the surveyors arrived October 1, 2012, and was not aware of the severity until "today" after obtaining the autopsy results for Resident #1. The Administrator stated he should be aware of any problems within the facility and said it was a huge task "in this size facility." The Administrator discussed the concerns with the Director of Nursing (DON) "today" and the plan was to get the "team" together and review what went wrong.

The Director of Nursing (DON) was interviewed on October 2, 2012 at 11:45 AM. She had not been aware of the details of Resident #1's death and had not completed an investigation. She stated the following:
- Due to the discrepancy in preadmission information pertaining to Resident #1's diet, clarification should have been obtained prior to writing the diet order;
- Nursing staff did not follow the facility procedure upon finding Resident #1 unresponsive in the dining room. She stated everyone had CPR/Heimlich training and staff should have followed that training for anyone choking or unresponsive;
- Updated information pertaining to aspiration precautions should have been in the "blue binder" and care plan; and
-The facility does not have a written policy for the admission process.

10 NYCRR 415.26

F520 483.75(o)(1): FACILITY MAINTAINS QA COMMITTEE

Scope: Pattern

Severity: Immediate Jeopardy

Corrected Date: December 14, 2012

A facility must maintain a quality assessment and assurance committee consisting of the director of nursing services; a physician designated by the facility; and at least 3 other members of the facility's staff. The quality assessment and assurance committee meets at least quarterly to identify issues with respect to which quality assessment and assurance activities are necessary; and develops and implements appropriate plans of action to correct identified quality deficiencies. A State or the Secretary may not require disclosure of the records of such committee except insofar as such disclosure is related to the compliance of such committee with the requirements of this section. Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions.

Citation date: October 3, 2012

Based on record review and staff interview conducted during the partial extended survey (#NY00120863), the facility failed to provide a quality assessment and assurance program (QA) that readily and effectively identified issues that caused serious harm to Resident #1, and with the potential to cause serious harm to Residents #2,3,4,5, and 6 who were identified at risk for choking. Additionally, the facility did not identify issues related to medical orders not written by the attending medical practitioner for residents on Units 6, 7, and 8. Specifically, QA failed to recognize the facility: did not provide adequate supervision for residents at risk for aspiration; did not follow protocol when a resident was found unresponsive in the dining room; and did not ensure physician orders were completed by the attending medical practitioner. This resulted in actual harm for Resident #1 with the potential for more than minimal harm that was Immediate Jeopardy to the health and safety of Residents #2, 3, 4, 5 and 6, and residents who resided on Units 6, 7 and 8. Refer to F281 and F323.
Findings include:

The Administrator was interviewed on October 2, 2012 at 1:30 PM and stated he was not aware of the problems until "yesterday" when the surveyors arrived at the facility and started the investigation. QA had not discussed these issues and the Director of Nursing (DON) was the chairman of the committee.

The DON was interviewed on October 2, 2012 at 11:45 AM and had not interviewed staff regarding the problems identified, until made aware by the surveyors. As a result, a quality assurance plan was initiated on this date,as a first step, and all dietary staff were in the process of reviewing all resident records for accuracy of dietary orders and for aspiration precautions.

10 NYCRR 415.27(a-c)

:

F281 483.20(k)(3)(i): SERVICES PROVIDED MEET PROFESSIONAL STANDARDS

Scope: Pattern

Severity: Immediate Jeopardy

Corrected Date: December 14, 2012

The services provided or arranged by the facility must meet professional standards of quality.

Citation date: October 3, 2012

Based on record review and staff interviews conducted during the partial extended survey ( #NY00120863 ), it was determined for residents residing on Units 6, 7 and 8, (including Resident #1 who resided on Unit 6), the facility did not provide services that meet professional standards of quality. Specifically, the facility failed to ensure admission diet orders were written and clarified by the attending medical practitioner. This resulted in actual harm to Resident #1 with the potential for more than minimal harm to residents residing on Units 6, 7 and 8, that is immediate jeopardy.
Findings include :

Resident #1 was admitted to the facility on July 16, 2012 following a surgical repair of a left hip fracture (July 8, 2012). The resident's ongoing diagnoses include dementia Alzheimer's type, chronic obstructive pulmonary disease (COPD - lung disease), and a history of pneumonia.

On July 16, 2012, the diet technician documented in a progress note that the resident was admitted from the hospital and the resident's diet order was "regular unmodified" with nectar thick liquids.

The New Admission Physician Orders dated July 16, 2012 and signed by the nurse practitioner (NP) had the diet order written in a different handwriting than the medication orders. The hand written order was for a regular unmodified diet with nectar thick liquids.

The NP's dictated "Admitting Note" dated July 16, 2012 documented the resident had a clinical swallow evaluation on July 10, 2012 "which recommended nectar thickened liquids with pureed trials resulting in her oral holding and the need for verbal cues to swallow." The resident was on aspiration precautions, and needed assistance with her oral intake. The NP documented "her diet will be soft with nectar-thickened liquids."

The NP was interviewed on October 1, 2012 at 2:40 PM regarding the physician orders. She reviewed the admission orders and stated though she signed the order, she did not write the order for the resident's diet. She stated, upon admission, the dietitian reviewed the information received by the facility, discussed the diet with the resident and/or family member and the dietitian wrote the diet on the initial orders. She said she communicated with the dietitian prior to an order being written and was aware of the diet prior to signing the orders. When asked to clarify the conflicting admission diet order for Resident #1 with the "admitting note" for this resident, she stated a regular unmodified diet was "similar" to a soft diet.

The registered dietitian (RD) was interviewed on October 1, 2012 at 3:25 PM and stated the facility policy was for either the RD or the diet technician to do the nutrition screen within 24 hours of admission. The screen included reviewing the "paperwork" and writing the diet order. The RD stated she did not write the July 16, 2012 order for Resident #1 to have a regular unmodified diet.

On October 2, 2012 between 4:00 PM and 4:30 PM, a surveyor interviewed the diet technician who was assigned to Resident #1's unit on July 16 and 17, 2012. She stated when a resident was admitted to the facility, she reviewed any paperwork that was available prior to the admission. The policy was for the screen to be completed by the RD or the diet technician within 24 hours of the admission. She stated if the paperwork on admission was "straightforward" she wrote the order on the physician orders. The NP always checked the order and was "ultimately responsible." She said she always worked with the same NP and this was their normal routine. She stated if there was any question or doubt about the consistency or diet order, she discussed it with the NP. In reviewing the admission order for Resident #1, the diet technician stated it was her own handwriting on the order form.

In summary, the facility did not ensure physician diet orders were completed by a qualified practitioner as it is not in the scope of practice for nutrition staff to write physician orders. (Refer to F323, example #1)

10NYCRR 415.11(c)(3)(i)