Regal Heights Rehabilitation and Health Care Center
Deficiency Details, Complaint Survey, December 16, 2011
Regional Office: MARO--New York City Area
F309 483.25: PROVIDE NECESSARY CARE FOR HIGHEST PRACTICABLE WELL BEING
Severity: Actual Harm
Corrected Date: January 31, 2012
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.
Citation date: December 16, 2011
Based on observation, interviews and record review during an abbreviated survey, the facility did not ensure a resident was provided the necessary services to maintain the highest practicable physical well-being in accordance with the comprehensive assessment and plan of care. This was evident in 1 of 3 sampled residents (Resident #1). Resident #1 was served zucchini, despite a documented zucchini allergy. Subsequently, the resident suffered an anaphylactic reaction and was transferred to the hospital. Additionally, the dietary and nursing staff were not aware of facility policies for identification of resident food allergies.
This resulted in actual harm that is not Immediate Jeopardy.
Complaint # NY00104452
The findings include:
Resident # 1 was a 60 year old male admitted to the facility on 7/14/11 with diagnoses including Fever, Lethargy, Bacteremia, End Stage Renal Disease, Diabetes Mellitus and Lower Back Pain secondary to Herniated Disc. The Minimum Data Set Assessment 3.0 dated 7/21/11 identified that the resident was cognitively intact. He required supervision in eating with no physical help from staff.
A review of the Nursing Admission Assessment dated 7/14/11 documented that the resident had food allergies to squash and zucchini.
The Comprehensive Care Plan (CCP) for Food Allergy initiated on 7/15/11 documented that the resident is allergic to zucchini and squash. The facility interventions included providing alternate vegetables and avoiding zucchini and squash.
A review of Resident #1's lunch meal ticket dated 7/28/11 documented that the resident was allergic to squash and zucchini. The allergy was identified on the meal ticket with an indicator of skull and crossbones next to these listed items.
On 7/28/11 the resident was served the Italian Blend Frozen vegetables during lunch. A review of the packaging for the Italian Blend Frozen vegetables revealed that the vegetables included zucchini.
A nurse's note dated 7/28/11 at 12:30PM documented that at 12:01PM the resident was noted to be holding his face in the main dining area. He was observed pointing at the meal plate. The resident was immediately taken to his room. The resident spit out one piece of cherry. A finger sweep was done and there were no food particles in his mouth. The resident's face was noted to be red with visible difficulty breathing. The nurses called a stat code. The nurse noted that the resident was not able to give verbal response except for " Epipen. " The MD was notified and ordered Epipen 0.3 milligrams (mg) intramuscular injection (IM) stat. The resident persisted with respiratory distress despite Epipen. The MD was notified and ordered Benadryl 50mg IM with immediate response. The generalized redness subsided and the resident was verbally responsive and was no longer in respiratory distress. The resident was transferred to the hospital. A nursing note dated 7/28/11 stated that the resident returned from the hospital emergency room at 4:30PM.
The policies and procedures on Resident Meal Service effective 2/2000 last reviewed on 6/03 documented a centralized tray system is used to plate meals. Each tray is identified by a computer-generated ticket (meal ticket) that includes the resident's name, room number, diet order, food preferences and allergies. A Food Service Supervisor individually checks the trays as they leave the tray assembly line to ensure accuracy of the diet and to maintain quality assurance. A review of the meal ticket revealed that the ticket contains the resident's identifying information, menu items, resident preferences with a " happy face " or " sad face " symbol and allergies with a skull and crossbones symbol.
A review of in-service records revealed that the CNA staff was in-serviced on meal consumption by the in-service coordinator on 4/6-4/9/2010. A review of the lesson plan revealed that the in-service did not include staff education related to residents' with food allergies.
On 8/3/11 at 10:00AM a telephone interview was conducted with Resident # 1. He stated that on 7/28/11 around 12:00PM he was served lunch that included Hawaiian chicken glazed with pineapple chunks, 2 or 3 cherries and mixed vegetables. Resident # 1 stated that the cherries had mixed with the juice from vegetables. He stated that he picked up a cherry and put it in his mouth. His lips started tingling and his throat started to feel like it was closing. He stated that he knew he was in trouble. While he was holding his throat, he tried to wave to the Certified Nurse's Aide (CNA) who was serving lunch. He stated that he was not able to talk. A few minutes later a CNA noticed him and called the Nurse. On his way to his room, he felt his whole body was shaking and swelling. Resident # 1 stated that the nurse did not know what was going on until he coughed out the cherry from his mouth. The staff administered an Epipen injection, but it did not work. He stated that he was given Benadryl and he felt better. He was transferred to the hospital via 911.
On 12/15/11 at 11:27AM a telephone interview was conducted with the Registered Dietitian who was assigned to the resident. The Dietitian stated that Resident #1 had a known food allergy to zucchini. She stated that the resident chooses his meal each day off of the menu. This is done with a CNA. The Dietitian stated that it is the responsibility of the food service staff to know the ingredients in all food items, know resident specific food allergies and prevent incorrect food items from being served to the resident. The Dietitian stated that all modifications for food allergies are done by the food service staff in the kitchen.
On 8/1/11 at 1:35PM the Dietary Aide Supervisor was interviewed. She stated that on 7/28/11 she was the " caller, " calling meal foods. She was responsible for informing the line staff what food items belonged on each tray. She stated that she was aware that Resident # 1 was allergic to zucchini and squash but she was not aware that the mixed vegetables had zucchini. The Dietary Aide Supervisor stated that she looked at the mixed vegetables and she did not see any zucchini. She thought that the mixed vegetables were the California Blend without zucchini. She stated that she is aware that the Italian Blend has zucchini.
On 8/1/11 at 2:25PM Dietary Aide # 2 was interviewed. He stated that he worked on the end of the tray line. He stated that he was working on the day of the incident. He was aware that the resident was allergic to zucchini and squash, but he did not see any zucchini or squash on the resident's tray. He stated that he was not aware that the Italian, California or Normandy blends of mixed vegetables contained zucchini.
On 8/1/11 at 3:20PM a telephone interview was conducted with CNA # 2. She stated that on 7/28/11 she gave the tray to Resident # 1 and left without opening the cover. CNA # 2 stated that the resident is alert and wants to open his tray. She stated that she was not aware that the resident' food allergy was written on the meal ticket. She was also not familiar with the meal ticket symbol for food allergy. CNA # 2 stated that she was not aware that the resident had a food allergy. She stated that prior to the incident she checked the meal trays for the resident's name and room number, but never checked diet or allergy.
On 8/1/11 at 11:50AM Dietary Aide # 1 was interviewed. She stated that she works as the starter in the tray line. Dietary Aide # 1 stated that on the menu ticket a sad face means food allergy or that a resident does not like the food. A happy face means a resident likes the food.
On 8/1/11 at 4:05PM CNA # 3 was interviewed. CNA #3 stated that a resident food allergy is identified on the bottom of the meal ticket. She stated that there are 2 faces on the meal ticket. The smiling face means not allergic and the sad face means allergic to certain food.
On 8/1/11 at 4:25PM CNA # 4 was interviewed, she stated that the symbol for food allergy is a sad face or not smiling face.
On 8/1/11 at 4:45PM CNA # 5 was interviewed. CNA # 5 stated that she never noticed the symbol for allergy on the meal ticket. She was not sure if the skull symbol was on the meal ticket until the 7/28/11 incident.
On 7/28/11 at 2:00PM the Dietitian #2 was interviewed. She stated that allergies are recorded in the meal ticket designated by a small skull and crossbones. A follow-up telephone interview was conducted with the Dietitian on 8/5/11 at 9:20AM. She stated that in the past 10 years the dietary staff was in-serviced that the skull and crossbones symbol stands for food allergies. The Dietitian stated that the skull and crossbones are for dietary staff only. She was not aware of training or in-servicing for the nursing department.
On 8/5/11 at 1:20PM a telephone interview was conducted with the Food Service Director. He stated that on orientation a dietary aide is shown a sample of the meal ticket and how to identify the symbols. According to the Food Service Director, a happy face indicates that a resident likes or can have that food, a sad face indicates that a resident does not like or cannot have that food and the skull and crossbones is to alert the staff the food is " not good. " The Director of Food Services stated that he has never in-serviced staff on specific food allergies, only the 3 symbols. He stated that the Dietitian also gives the staff in-service. A follow-up interview was conducted on 12/15/11 at 11:52AM. The Food Service Director stated that the cook informs the kitchen line staff of the ingredients of the food items that are being served.