Morris Park Nursing Home

Deficiency Details, Complaint Survey, March 8, 2011

PFI: 1235
Regional Office: MARO--New York City Area

Back to Inspections page


Scope: Isolated

Severity: Actual Harm

Corrected Date: May 6, 2011

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: March 8, 2011

Based on staff interviews and record review during an abbreviated survey, the facility did not ensure that a resident received adequate supervision to prevent accidents. This was evident for one (1) of four (4) sampled residents (Resident #1). Resident #1, with a known history of wandering, stealing food and on aspiration precaution, choked and expired after eating unsupervised in his room.

This resulted in actual harm that is not Immediate Jeopardy.

Complaint ID # NY00090722

The finding is:

Resident #1 was a 68 year old male, admitted at the facility on 2/1/06. His diagnoses included Vascular Dementia with behavioral disturbance, Coronary Artery Disease, Gastro Esophageal Reflux Disease, Psychosis, Aphasia, Dysphagia, status post Cerebral Vascular Accident (CVA), Diabetes Mellitus, and Hypertension. The Minimum Data Set Assessment 2.0 (MDS) dated 8/15/10 documented the resident has short and long term memory problems and moderately impaired cognitive skills for daily decision making. According to the MDS the resident had chewing and swallowing problems and requires limited assistance of one person during eating.

The Eating/Feeding Comprehensive Care Plan (CCP) initiated on 2/26/10 documented that the resident required intermittent supervision with set up related to impaired cognition, vascular Dementia, CVA, Dysphagia and high risk for aspiration. On 8/13/10 after readmission to the facility the feeding requirement changed to limited assistance during eating. Interventions included verbal cues, providing limited assistance in feeding, assessing feeding status quarterly or as needed, referring to speech therapist for swallowing evaluation, providing with ordered diet and liquids, and observing for aspiration precautions.

The Behavior CCP initiated on 5/7/10 and re-evaluated on 8/13/10, documented that the resident was physically abusive towards staff, aggressive towards other residents and wandered into other rooms taking food. Additionally, the resident refuses medication, resists care and takes food from food trucks. Interventions included, providing psychiatry consult, monitor behavior and re-directing resident away from exit doors, other resident's rooms and food pantries.

The Alternate Choice CCP dated 8/13/10 documented that the resident refused to eat in the unit dining room. Interventions included, providing Spanish speaking staff to translate as needed, and re-approach/reinforce for resident to eat meals in the unit dining room consistently.

The Resident's swallowing evaluation dated 6/21/10 documented that the resident had moderate oral-pharyngeal Dysphagia characterized by difficulty with bolus formation, bolus movement, labial loss of bolus and intermittent coughing with some nectar liquids. The resident is extremely self-directed and does not follow commands. The recommendation is to continue pureed diet with nectar thickened liquids. Also offer extra nectar thickened liquids with meals and in between meals to prevent self-directed taking of thin liquids and risk of aspiration.

The facility's daily menu dated 8/15/10 through 8/21/10 documented that sliced peaches were served during dinner on 8/15/10.

Resident #1's 8/15/10 dinner menu documented that he received a pureed meal with nectar thickened liquids.

Nurse's notes dated 8/15/10 from 5:10 PM to 7:30 PM documented that the resident was served dinner in his room. At 5:33 PM Code blue was called. The resident was noted with no vital signs obtainable. Mouth check was done and no foreign objects were noted. According to the CNA (Certified Nursing Assistant) the resident was walking in the hallway and collapsed. CPR (Cardiopulmonary resuscitation) was initiated at 5:34 PM and 911 was called. EMS arrived on the unit and took over. As EMS was intubating the resident, "1/2 processed peach was removed from resident's throat". The resident was pronounced dead by EMS at 6:14 PM.

The Facility Accident/Incident Report dated 8/15/10 documented that the CNA saw the resident walking and talking in the hallway on the unit. The CNA approached resident to help him when he realized that the resident had slurred speech. The CNA called the nurse immediately. No signs or symptoms of distress were noted at that time. The resident and the CNA continued to walk in the hallway towards the nursing station, while the resident continued talking with slurred speech that was unusual for him. After reaching the nurse station he suddenly collapsed. The CNA carried him to the nearest chair and resident was sitting on the chair with 2 CNAs supporting him. The LPN checked the resident and there were no vital signs noted and no obstructions in the mouth. The supervisor called 911, put resident on the nearest bed and initiated CPR. EMS arrived 5:45PM and took over.

The Facility's summary of investigation dated 8/15/10 documented that the resident was pronounced dead at 6:14 PM by EMS personnel and the family was notified. The supervisor was asked to obtain statements from all staff. "The patient plan of care and staff interviewed (statements) was reviewed, it was concluded that the staff followed the plan of care".

The 7-3 PM Registered Nurse Supervisor (RNS) was interviewed on 9/8/10 at 9:50 AM. The RNS stated that the residents are monitored in the main and unit dining rooms during meals. She stated that "no one particularly monitors the residents eating in their rooms". The RNS stated that the resident is known to take food from the pantry and is redirected by staff. However the resident speaks Spanish and they need more Spanish speaking staff to communicate with him.

The Dietician was interviewed on 9/8/10 at 6:30 PM. She stated that she has seen the resident stealing ice cream and sandwiches from the refrigerator on multiple occasions. The Dietician reported the incidents to nursing staff. She stated that the staff knows about the resident's behavior and "that's why we have to watch him".

The 3-11 PM regular Registered Nurse (RN) was interviewed on 9/8/10 at 6:59 PM. The RN stated that she saw two CNAs holding the resident and before she reached to the resident he already fainted in front of the nurse's station. She instructed one CNA to get oxygen and another CNA called Code Blue. The RN initiated CPR until the RNS arrived to help.

The 3-11 PM RNS was interviewed on 9/8/10 5:35 PM. The RNS stated that she responded to the Code and the CPR was in progress. The RNS called the MD and then took over the CPR. The EMS personnel arrived and continued with CPR. The RNS stated that EMS suctioned and intubated the resident. She saw the EMS personnel pull a processed peach measuring 3 cm (centimeter) by 1cm out of the resident's mouth. The resident expired at 6:15 PM. The EMS personnel then told the RNS that they found a peach in his throat during intubation.

The assigned 3PM-11PM CNA was interviewed on 9/8/10 7:00 PM. The CNA stated that the resident is known to take food from the floor, food carts and other resident's trays. He stated that the resident is encouraged to eat in the dining room but he prefers to stay in his room. The staff "knows the way he is". On 8/15/10, between 5:15 PM and 5:20 PM, the CNA served the resident dinner in his room. He had a pureed meal with thickened liquid and soft fruit juice. The CNA stated that the resident's roommate, who is on a chopped consistency diet, was also eating in the room. The CNA set-up Resident #1's food and then left the room to watch other residents in the dining room. At approximately 5:25 PM the CNA saw the resident walking from his room towards the nurse's station. The resident's face looked dark red and he had slurred speech. The CNA walked down the hall with the resident towards the nurse's station and then he collapsed. The CNA called the nurses for help and they sat the resident on a chair. The RN checked the resident's vitals and then called a code. The resident was then put to bed and CPR was started. The CNA stated that the resident's "color was changing so fast as soon as we put him to bed and his eyes were closed".

415.12 (h)(2)