Wingate at Beacon

Based on observations, interviews and record review during an abbreviated and partial extended survey, the facility failed to have systems in place to adequately monitor and supervise residents who are at risk for choking. The facility failed to: ensure that policies and procedures were implemented to prevent accidents and injuries to residents who required supervision during meals due to known swallowing problems and to provide the proper food consistency for residents on mechanically altered diets. The facility failed 1)to follow a physician' s order to feed Resident #1 at all meals and 2) to follow the care plan requiring supervision of Resident #2 at all meals. Specifically, Resident #1 was on a mechanically altered diet due to dysphagia (difficulty swallowing) and a history of choking, and had a physician's order to be fed at all meals. This resident expired due to aspiration of a whole, peeled hard-boiled egg when she was left alone to feed herself during a breakfast meal that did not contain food items with the proper consistency.
This resulted in actual harm for Resident # 1, and no actual harm with the potential for more than minimal harm for Resident #2, and the potential for serious harm for 94 residents who had swallowing difficulties and mechanically altered diets. This resulted in Immediate Jeopardy for residents' health and safety and Substandard Quality of Care.
Complaint ID Number: NY 00095716
The findings are:
1. Resident #1 is a 46 year-old female with diagnoses including Multiple Sclerosis with Tremors, Dysphagia (difficulty swallowing) and Seizure Disorder.
A review of the Swallowing Screen performed by the facility's Speech Language Pathologist (SLP) on 12/24/09 indicated that this resident was to be supervised and assisted at all meals, to continue the Ground Diet with extra gravy and to notify the Speech Therapist of any changes. This evaluation was ordered immediately after this resident had a severe choking episode on 12/23/09 that required the Heimlich maneuver after choking on a large amount of "magic cup" ( a thick ice cream-like substance). A physician's order was written at that time for the resident to be fed by staff per the speech therapist evaluation performed on 12/24/09.
A review of the resident's Minimum Data Set (MDS)(an evaluation tool) dated 11/05/10 revealed that this resident was independent with decision making. The MDS further revealed that this resident required guided maneuvering of her limbs and other assistance by staff.
A review of the Comprehensive Care Plan (CCP) for Nutrition dated 11/11/10 documents that the resident is a nutritional risk related to her diagnoses of Multiple Sclerosis and Depression. The CCP states that the resident is to be fed by staff " at times" due to choking and swallowing issues. The interventions included providing the resident with a Ground Diet with extra gravy and assist with meals as needed. Goals for the resident were that she will have a good food and fluid intake, maintain her weight and will not aspirate (inhale food into her lungs).

The facility's Policy and Procedure regarding Aspiration Precautions for the residents at risk states: " POLICY: Precautions are taken to minimize the possibility of aspiration for residents that are high risk. PROCEDURE: 1. Identify residents at risk for aspiration. These include, but are not limited to the types of residents: a. without adequate gag reflux. b. with history of choking. c. with difficulty swallowing. d. receiving thickened liquids. 2. Keep the head of the bed elevated at least 45 degrees after meals. 3. Feed residents with the head of the bed elevated 90 degrees and preferably out of bed. 4. Thicken all liquids to appropriate consistency as recommended by speech therapy and ordered by the Physician. "
According to the facility investigation of the incident the resident was found unresponsive by staff on 12/29/10 at 8:50AM. Cardio-Pulmonary Resuscitation was started and 911 Emergency was called. Attempts to revive the resident were unsuccessful as well as attempts to clear her airway. Paramedics arrived and attempted to clear her airway. They used long tongs to remove the blockage, a hardboiled egg. The resident was pronounced dead by the hospital Emergency Room Physician-via telephone at 9:23AM. During an interview with the assigned C.N.A on 12/31/10 at 1:00PM she stated she brought the breakfast tray to the resident on 12/29/10 and it contained a whole, peeled boiled egg and 2 pieces of toast. The C.N.A. further revealed she was not aware that Resident #1 had a swallowing problem.
During a telephone interview with the attending Physician on 12/30/10 at 12:30 P.M. regarding Resident #1, he stated that "due to her tremors the resident was to be fed by staff." A review of the physician's orders for each month from 12/09 through 12/10 following the choking episode on 12/23/09 revealed that there was a physician's order that the resident be fed by staff.
The Certified Nurse Aide (CNA #1) assigned to Resident #1 on 12/29/10 was interviewed on 12/31/10 at 1:00 P.M. She stated that she brought the resident her breakfast tray on the morning of 12/29/10. The breakfast consisted of 2 pieces of toast and a whole, peeled, hard-boiled egg. The CNA added that she was not aware that Resident #1 had a swallowing problem and that the resident was to be fed. This CNA also added that this resident was a fast eater. The CNA stated she was aware that this resident had an order for a ground diet, but didn't know the resident had a swallowing problem.
A review of the Nurses Notes dated 12/29/10 at 8:50 A.M. revealed that a Certified Nurse Aide (CNA #2) summoned the Licensed Practical Nurse (LPN#1) to the resident's room after the CNA found the resident unresponsive. LPN #1 indicated in her note that " resident's skin was blue and skin clammy, she was without a pulse and respirations. " This note continues to document that Cardio-Pulmonary Resuscitation (CPR) was initiated and 911-Emergency was called. Paramedics arrived at 8:58 A.M. and they continued CPR until 9:23AM. The resident remained unresponsive with no cardiac rhythm or spontaneous respirations. The resident was pronounced dead at 9:23AM. by the Hospital Emergency Room Physician via telephone to the Paramedics.
An interview was conducted with the facility's Medical Director on 12/30/10 at 11:30 A.M. The Medical Director stated that the EMT's (Emergency Medical Technicians) removed a hard-boiled egg from Resident #1's airway with long tongs, as they were unable to pass an ET tube (endo-tracheal tube- artificial airway) as the airway was obstructed. The Medical Director further stated that the Medical Examiner's preliminary findings from an autopsy of the resident determined that Resident #1 died from "Asphyxiation by Food Bolus in Airway."
The Director of Nursing (DON) was interviewed on 12/30/10 at 3:30 P.M. During the interview the DON stated that the facility had already identified five (5) "problems" with respect to Resident #1. This included: (1) a monthly physician's order for each month from 12/23/09 through 12/15/10 that required that the resident be "fed by staff; " (2) a speech evaluation on 12/24/09 that recommended this resident be supervised and assisted at all meals; (3) the CNA Care Guide did not state "fed by staff;" (4) the Activities of Daily Living Care Plan did not document that the resident was to be "fed by staff;" and (5) after the annual Comprehensive Care Plan Meeting on 08/17/10 with the Registered Nurse (RN) Unit Manager and the Social Worker, the original Physician's Order, requiring the resident be fed by staff, was disregarded because they deemed Resident #1 to be more independent with eating.
The Registered Nurse (RN) Unit Manager was interviewed on 12/31/10 at 4:00 P.M. The RN stated that on 08/17/10 she attended the Annual Care Plan Meeting with the facility Social Worker. The RN explained that at this meeting they discussed the resident's improved level of assistance with feeding and the decision was made (between the RN and Social Worker) to upgrade the resident. The RN and the Social Worker determined that the resident was able to feed herself with physical assistance by staff as needed. When the RN was asked if the Physician was notified of this resident's progress and whether a Swallowing Screen was ordered, the RN replied " no. "
Review of the C.N.A. Care Guide dated 8/17/10 revealed the resident was now able to feed herself, was independent with tray set-up and was not at risk for aspiration.
The Director of Rehabilitation was interviewed on 12/31/10 at 9:40 A.M. She stated that if staff want to "upgrade" a resident (make a change in the resident's level of assistance with feeding where less supervision is required) they must first have a Swallowing Evaluation performed for that resident.
The DON was re-interviewed on 12/31/10 at 10:15 A.M. regarding the upgrading of residents' assistance with feeding. The DON stated anyone on staff can " downgrade " a resident (requiring more assistance with feeding) but only the Physician or the Speech Language Pathologist (SLP) can upgrade a resident per the facility Policy and Procedure on Diets.
Review of this Policy and Procedure includes but not limited to:"1.Nursing, Dietary, Occupational and Physical Therapy/Speech therapy may make recommendations about diets, but all diets must be ordered by the attending Physician and recorded in the resident's record. 2. Nursing is responsible for forwarding resident information by way of a "Dining Services and Nutrition Communication Form".
An interview was conducted with the Dietary Technician (DT) on 12/31/10 at 9:50 A.M. The DT stated that the resident had a good appetite, her weight was stable and she saw the resident in the dining room feeding herself. She added that the resident frequently went to the facility's Caf for snacks. When asked if the resident was supervised while eating at the Caf, the DT replied "no." The DT further revealed she was unaware that the resident was supposed to be fed by staff.
The Administrator was interviewed on 12/30/10 at 4:00 P.M. He stated " there were things we could have done better. " In a further interview on 12/31/10 at 3:00PM, the Administrator revealed that he was of the opinion that a " hard boiled egg is a finger food."
2.Resident #2 has diagnoses including Cerebral Vascular Accident (CVA) with Aphasia, Dysphagia and Blindness of Right Eye.
A Swallowing Evaluation was performed for this resident on 12/03/10 by the SLP. The SLP made the following recommendations regarding this resident: (1) needs cues and supervision at all times during all meals; (2) diet is Ground Moist with no bread and Nectar Thick Liquids; (3) resident is to be up in a chair for all meals; (4) resident is an Aspiration Risk; and (5) during consumption of meals this resident is to follow the SLP's instructions which are to " put the spoon down and swallow before the next bite of food, take small sips of liquids, tuck chin and double swallow fluids and staff to check the resident's Left Cheek for pocketing" The Physician concurred with these recommendations.
Resident #2's Dietary Care Plan and CNA Care Card documented that the resident is to be supervised at all times for meals, requires cues during eating and swallowing, on aspiration precautions and diet is Ground moist, no bread, and with nectar thick liquids. The resident is to be out of bed for all meals and the SLP directions to be followed. The Physician concurred by his initials on the Swallow Evaluation recommendations form.
During observation of the facility's dinner meal on 01/02/11 at 5:45 P.M. Resident # 2 was observed in his room. The resident was sitting in a chair eating his meal, which was in front of him on a table. No staff members were present as he ate his food.
Immediately after this observation, the Charge Nurse was asked if Resident # 2 required supervision and assistance during meals. The Charge Nurse replied " Yes he should. "

415.12(h)(1)

The Administrator failed to ensure that the facility was administered in a manner that enables the facility to use it resources effectively and efficiently to attain or maintain the highest practica ble physical , mental, and psychosocial well-being of each resident. This resulted in actual harm for Resident #1 with the potential for serious harm for 94 residents with swallowing difficulties, mechanically altered diets that is Immediate Jeopardy for residents' health and safety .
Findings are :
The Administrator failed to ensure that the facility operates in a manner that enables it to effectively use it resources to maintain the highest practicable well-being and safety of each resident. Specifically, the f acility Administrator failed to ensure adequate supervision was provided for R esident #1 identified as an Aspiration Risk and for 94 other residents with swallowing difficulties and with mechanically altered diets. . The Facility Administrator failed to ensure that the Nursing Staff , Certified Nursing Aides and Dietary Staff were knowledgeable of their job duties and performed monitoring responsibilities in a manner that en sured that residents requiring varying degrees of supervision, received the appropriate level of supervision .The f acility Administrator failed to ensure that the Nursing Staff ,Certified Nursing Aides and Dietary Staff verified meal consistency for residents and that the residents received the correct meal consistency.
During an interview with the Administrator on 12/30/2010 at 3:30pm he stated " we could have done things better".
415.26

Based on record review and staff interviews , the facility failed to ensure that residents received food in the appropriate form as ordered by the physician. This was evident for 1 of 5 residents reviewed during an abbreviated survey. (Resident #1).
Specifically, Resident #1 did not receive food in the ground form as ordered by the physician. The resident received a whole, peeled, boiled egg on her breakfast tray and aspirated ( inhale food or fluid into the respiratory tract) . Paramedics were able to remove the egg with tongs. The resident never regained consciousness and subsequently expired.
This resulted in actual harm for Resident #1 with the potential for serious harm for 94 residents with swallowing difficulties, mechanically altered diets that is Immediate Jeopardy for residents' health and safety and Substandard Quality of Care.
Findings are:
Complaint # NY00095716
Resident #1 was admitted to the facility on 3/30/07 with diagnoses including Multiple Sclerosis with tremors, Dysphagia (difficulty swallowing) and Seizure Disorder. The Minimum Data Set 3.0(MDS- a resident assessment tool) dated 11/5/10 documented the resident was on a mechanically altered diet .
Review of the Comprehensive Care Plan (CCP) for Nutrition Risk dated 8/10/10 documented the " resident is to be fed by staff at times " based on chewing and swallowing issues. The goal for this resident was that she will not aspirate.
Review of the Nutrition Care Progress Notes written by the Dietary Technician (DT) dated 11/11/10 reveal the resident feeds herself with supervision and physical assist of staff at times. It further documents she saw the resident eating snacks at the facility's caf . During an interview with the DT on 12/31/10 at 9:50 AM she revealed she was not aware the resident was to be fed by staff but she stated she observed Resident #1 eating candy and pretzels in the cafe.
Review of the most recent Physician's orders revealed the resident was on a ground diet with extra gravy. It further documented the resident was to be fed by staff for meals. This order was consistently renewed on the monthly orders from 12/2009 through 12/2010.
Review of the facility policy entitled " Dietary Consistencies and Descriptions" for the Ground diet revealed all egg items must be ground.
Review of the Certified Nursing Assistant (C.N.A.) Care Card documents the resident "feeds herself especially when eating finger foods" and is not at risk for aspiration. The diet consistency listed on the CNA care card states "ground with extra gravy".
The Incident/Accident report states the resident was found unresponsive by staff on 12/29/10 at 8:50AM. Cardio-Pulmonary Resuscitation was started and 911 Emergency was called. Attempts to revive the resident were unsuccessful as well as attempts to clear her airway. Paramedics arrived and attempted to clear her airway. They used long tongs to remove the blockage, a hardboiled egg. The resident was pronounced dead by the hospital Emergency Room Physician-via telephone at 9:23AM. During an interview with the assigned C.N.A on 12/31/10 at 1:00PM she stated she brought the breakfast tray to the resident on 12/29/10 and it contained a whole, peeled boiled egg and 2 pieces of toast. The C.N.A. further revealed she was not aware that Resident #1 had a swallowing problem.

During an interview with the Medical Director on 12/30/10 at 11:30AM he stated that the Medical Examiner performed an autopsy and the cause of death was "asphyxiation by food bolus".

According to review of the "American Dietetic Association, Food lists for Dysphagia- Mechanically Altered Diet", copyright 2002, hard-boiled eggs are to be avoided. It further documents that foods are to be moist, with small pieces to make them easy to chew and easy to swallow.

415.14( d)(3)

Based on observations, record review and interview the facility did not ensure that staff followed acceptable standards of nursing practice. The facility failed to ensure that; 1) the resident received the appropriate dietary consistencies and supervision in accordance with physicians orders. 2) Resident care plans, dietary flow sheets and Certified Nursing Assistant (CNA) Care Cards were consistently updated 3) Physician's Monthly Orders were transcribed to resident care plans and forwarded to the appropriate facility departments (i.e. Dietary).This was evident on 4 of 4 facility Units (Orange, Putnam, Ulster and Dutchess) and for 5 of 5 sampled residents.

Specifically, Resident # 1 with a history of difficulty swallowing was not provided the supervision ordered by the Physician from 12/09 through 12/ 10. She subsequently expired due to choking and aspiration of a hard-boiled egg. Further, her level of assistance was upgraded on 8/17/10 without an order for a speech evaluation or a physician's order. 2) The CNA Care Card for Resident # 2 documented that he was to be supervised at all times during meals. During surveyor observation on 1/2/10 at 5:45pm he was observed in his room with his tray in front of him with no staff present.

This resulted in actual harm for Resident #1 with the potential for serious harm for 94 residents with swallowing difficulties, mechanically altered diets that is Immediate Jeopardy for residents' health and safety and Substandard Quality of Care.

Findings are:

Complaint # NY00095716

Resident # 1 is a 46 year old female with diagnoses including Multiple Sclerosis with tremors, Hypertension and Dysphagia (difficulty swallowing). This resident had a choking episode on 12/23/09 that required the Heimlich maneuver after choking on a large amount of " magic cup " (a thick ice cream-like substance). A physician's order was written at that time for the resident to be fed by staff per the speech therapist evaluation performed on 12/24/09.
Review of Physician's Orders revealed that all orders for the months of 12/09 through 12/10 remained the same "Fed by Staff ".

Review of the facility In-service records provided by the facility Pharmacy regarding transcribing orders documents that "the entire ancillary orders (orders regarding diets, treatments, and Do Not Resuscitate orders) match exactly and a second edit must be done just prior to turnover (a change in monthly orders). This edit involves a second nurse checking the new Medication Administration Records (MARS) and Treatment Administration Records (TARS) to the previous ones looking for any discrepancies".

Review of the resident's Annual Care Plan Meeting that took place on 8/17/10 revealed that the RN (Registered Nurse) Unit Manager and the SW (Social Worker) independently upgraded the resident's feeding needs and revised the CNA Care Card to reflect that the resident was independent with set up and could feed herself finger foods and required physical assistance with feeding only as needed. The CNA Care Card documented that the resident was not at risk for aspiration (inhale food or fluids into the respiratory tract). This was contrary to the current Physician's order.

Review of the Activities of Daily Living Flow Sheets from 12/09 through 12/10 provides documentation by the CNAs that describes varying levels of assistance required by the resident from independent to total dependence for all three meals.

During an interview on 12/31/10 at 4:00pm the RN Unit Manager was asked if she had requested a speech evaluation prior to upgrading the resident's level of assistance. She replied "no".

Further review of the medical record revealed no documentation about the Annual Care Plan meeting regarding the change made in the resident's level of assistance for feeding. It did not address the decision made by the attendees that the resident was now able to feed herself despite a physician's order that she be fed by staff.

415.11(c)(3)(i)