Huntington Hills Center for Health and Rehabilitation

Based on record review, observation and staff interviews during an abbreviated survey, the facility did not ensure that each resident assessed at risk for accidents received adequate supervision and assistive devices to prevent accidents. Specifically, one of three residents identified with difficulty in swallowing and fed by Gastrostomy Tube (GT) reviewed for aspiration precaution was not provided adequate supervision to prevent the resident from consuming foods by mouth and possible aspiration . This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.
(Resident #1)

NY00086019

The finding is:

Resident #1 age 87 admitted on 4/30/10 with diagnoses including Dysphagia, chronic airway obstruction and is fed by GT.

The Minimum Data Set Assessment (MDS) dated 5/23/10 documented the resident's cognition as moderately impaired.

A swallow study dated 4/6/10 for Resident #1, documented the recommendation was NPO (nothing by mouth).

The Comprehensive Care Plan (CCP) for activities of daily living (ADL) dated 4/15/10 documented supervision of food and fluid intake secondary to non compliance with NPO.

The Physician Orders dated 5/7/10 documented NPO, aspiration precautions and GT feeding and on 5/13/10 at 5:46 PM chest x-ray STAT (immediately) to rule out aspiration.

The Progress Notes dated 5/13/10 at 9:25 PM by Registered Nurse (RN)#16 documented that Resident #1 was alert, transferred to the hospital with rule out aspiration, increased breath sounds included rales with sputum production. Vital signs: blood pressure 128/82, pulse 79, respirations 24.

At 11:45 PM the RN Supervisor (RNS) #19 documented that Recreation Therapy Aide (RTA) #13 reported that Resident #1 ate a piece of solid food. The resident was congested, leaning forward in a chair attempting to clear his throat and was speaking. A nebulizer treatment was given and his mouth was clear of food particles. The Medical Doctor (MD) was notified.

On 5/14/10 at 8:50 AM, Licensed Practical Nurse (LPN) #20 documented the result of the chest x ray dated 5/13/10 was left upper lobe infiltrate. The MD was made aware.

On 5/14/10 at 3:26 PM RNS #19 documented it was reported that Resident #1 was noted to be holding a piece of food near his mouth with a bite taken out of it, the resident was leaning forward in chair, pale, congested and was able to speak The MD was made aware.
At 3:31 PM the resident was in respiratory distress and the MD was informed. At 9:30 PM, Resident #1 was having respiratory distress; a nebulizer treatment was in progress. The MD was called and the resident was sent to the hospital.

The Accident Report dated 5/13/10 at 3:30PM documented that in the 1A/B Main Dining room/ activity room the Recreation Aide #13 (RA) noticed that Resident #1 was holding a piece of food near his mouth. The RA #13 immediately removed a potato puff; there was a bite taken out of it.

The Discharge Summary from the hospital dated 5/18/10 documented possible aspiration pneumonia.

The Certified Nurses' Accountability Record dated 5/10 documented aspiration precautions.

The facility's policy for Dysphagia Management /Aspiration Precaution documented that residents/patients must be supervised while eating.

The Director of Nursing (DON) was interviewed on 5/27/10 at 9:15 AM, she stated that the incident was investigated and the staff was aware that Resident #1 was NPO; however, Resident #1 was found with food in his mouth and hand. It was thought, that the resident grabbed the food from another resident. The DON stated that initially Resident #1 was alone at the table but later other residents sat at the table with him. She further stated that armbands for aspiration precautions have green dots with the letter " A " for NPO and/or aspiration precautions. A member of the dietary department places a list of residents with special diets on the wall of the pantry area. However, a copy of the list was not available.

The Director of Recreation Therapy (DRT) was interviewed on 5/27/10 at 12:10 PM, she stated that on 5/13/10, there was a party in the 1 A/B dining room, snacks that included cheese puffs were provided to the residents at the tables. The DRT was told by a RA (name not recalled) that Resident #1 was not permitted to have any food or fluids. Throughout the Recreation Therapy (RT) program the DRT observed Resident #1; he was not eating or drinking anything. It was later (time not recalled) reported by RA #13 that Resident#1 was found with one half of a cheese puff in his hand with a bite taken out of the cheese puff. The DRT stated that she is verbally told by the nursing staff of the residents who can't eat or drink. A list of residents' names is also posted in the pantry. She further stated armbands with green dots and the letter " A " are for NPO and/or aspiration precautions; she did not recall if Resident #1 was wearing this armband at the time of the incident. The DRT stated that the staff are to ensure that residents who are NPO should not sit at the same table with residents who can eat and she did not observe that Resident #1 was seated at the same table with other residents who could eat; this was an oversight on her part.

On 5/27/10 at 1:25 PM during an interview with RA # 13, he stated that Resident #1 was sitting at a table with other residents on 5/13/10 during the RTA. He knew that the resident was NPO and he advised the other staff. The RA continued to observe Resident #1 throughout the activity. Near the end of the activity he saw Resident #1 with half of a potato puff in his hand and he removed it; the resident was chewing but he did not look in the resident's mouth. The RA immediately called the nurse and brought the resident to the nurses' station. The RA recalled that Resident #1 had no trouble breathing at that time. The RA was not sure if residents who are NPO can be seated with residents who can eat.

The RA #18 was interviewed on 5/27/10 at 1:45 PM, she stated that she checks the dietary list for special diets. She tries to get the residents who can eat by mouth to sit together but not at the same table with residents who can't eat by mouth. She did not recall who sat the resident at the table during the activity.

On 5/27/10 at 2:45 PM, the 1 B Unit 2:30 PM-10:30 PM shift CNA (Certified Nurses Aide) #15 who was on duty on 5/13/10 was interviewed, CNA #15 stated that she brought Resident #1 to the RTA on 5/13/10 and sat him near a table. She told the Recreation Therapy staff that the resident was NPO.

On 5/27/10 at 3:20 PM, the 2:30 PM-10:30 PM RNS #19 who was on duty on 5/13/10 was interviewed, RNS #19 stated that at 6:00 PM she was called to the unit to observe Resident #1. RNS #19 assessed Resident #1, the Resident was stable, was not coughing and his breath sounds were diminished. The MD was made aware, he ordered a chest x-ray and monitoring for Resident #1. At 9:00 PM, the RNS #19 observed Resident#1 in respiratory distress and a nebulizer treatment was administered. The MD was contacted and ordered the resident to be sent to the hospital

415.12(h)