cms_DC: 68
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 68 | SERENITY REHABILITATION AND HEALTH CENTER LLC | 95015 | 1380 SOUTHERN AVE SE | WASHINGTON | DC | 20032 | 2018-07-20 | 684 | G | 0 | 1 | L7I811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, personnel records review and staff interviews for two (2) of 56 sampled residents, the facility failed to provide necessary care and treatment with an acute change in condition as evidenced by failure to perform a comprehensive assessment and reassessments to determine appropriate treatment and interventions to prevent Harm and prevent hospitalization for one (1) resident (Resident #158) with [DIAGNOSES REDACTED].#158, and #96. Findings included . 1. Facility failed to provide necessary care and treatment with an acute change in condition as evidenced by failure to perform a comprehensive assessment and reassessments to determine appropriate treatment and interventions to prevent hospitalization for Resident #158. On (MONTH) 17, (YEAR), the State Agency received a facility reported incident that showed that Resident # 158 experienced a choking episode with total airway obstruction on (MONTH) 17, (YEAR) at approximately 9:50 PM. The resident subsequently became unresponsive. Cardiopulmonary resuscitation was initiated and the resident was transported to the emergency room . Resident #158 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Speech Evaluation and Plan of Treatment dated (MONTH) 13, (YEAR) at 4:38 PM showed reason for referral: Resident referred to SLP (Speech Language Pathology) evaluation due to difficulty speaking and coughing while eating. The speech evaluation included recommendations for mechanical soft textures, mechanical soft/ground textured solids; nectar thick liquids with close supervision for oral intake. Swallowing strategies included seated in chair or edge of bed for all PO (oral) intake. Liquids consumed with head posture chin down. Review of medical record on [DATE] at 10:00 AM showed an Admission Minimum Data Set ((MDS) dated [DATE]. Review of the MDS Section C showed the Brief Interview for Mental Status score was coded as 13, which indicates the resident is cognitively intact. Section G0110 (Functional Status) Resident # 158 was coded as requiring supervision for all activities of daily living except bed mobility, personal hygiene and bathing. Under section G0120 (Bathing) resident is coded as 4 which indicates total dependence. Section G0110 Eating resident was coded as 1 which indicates set up help only. Under Section K0100 (Swallowing/Nutritional Status) resident was coded as none of the above for Swallowing Disorder. However, under Section K0510 (Nutritional Approaches) the resident is coded as requiring a mechanically altered diet (requires change in texture of food or liquids, e.g. pureed food, thickened liquids). Review of the Nutrition problem care plan dated [DATE], showed interventions listed as provide regular mechanical soft diet as ordered. A further review showed an ADL Self-care Performance Deficit care plan initiated on [DATE], with the following interventions praise all efforts at self-care, physical therapy and occupational therapy evaluation and treatment as per doctor orders, staff to assist with bed mobility and transfers, as well as locomotion on and off unit as needed, staff to assist with hygiene and toileting as needed, encourage resident to participate to the fullest extent possible with each interaction and encourage resident to use call bell to call for assistance. Review of the Oral/Dental Health problem care plan dated [DATE] showed the resident has difficulty in chewing and broken teeth need for altered textured diet, Interventions the resident requires mechanical soft diet. Consult with dietician and change if chewing/swallowing problems are noted. The medical record lacked documented evidence the care plan included swallow strategies recommended by the speech therapist. Speech Therapy Treatment Encounter note dated [DATE] at 5:42 PM, showed regular nectar thin liquids presented mild cues for head posture chin down during liquid intake. The Nurse's Note dated (MONTH) 17, (YEAR), at 11:15 PM showed that Resident #158 was in the Day Room with other residents eating a steak and cheese sub from a local carry out when a staff member yelled for help at about 9:40 PM. Upon entering the Day Room, the nurse observed the resident sitting in his wheelchair coughing/choking and his eyes rolling backward. The nurse called for help and performed five (5) back blows on each shoulder blades. Resident #158 coughing increased. In addition, the Nurse's Note showed abdominal thrusts were performed three (3) times but the resident condition is not improved. He went into code and CPR (Cardiopulmonary Resuscitation) was initiated and 911 was called, resident was intubated and then transferred to (Hospital Name). The medical record lacked documented evidence the nursing staff provided verbal cues to Resident #158 while eating the steak and cheese in the Day Room, to prevent choking. Further review of the medical record showed an eInteract Change of Condition Evaluation Form dated (MONTH) 17, (YEAR), at 9:59 PM. The form showed Resident #158's [DIAGNOSES REDACTED]. The most recent vital signs recorded as [DATE] at 9:40 AM- ,[DATE], pulse- 78 beats per minutes, respirations- 20 breaths per minutes, and the most recent temperature recorded as 98.4 degree Fahrenheit orally at 2:28 PM on (MONTH) 17, (YEAR). The most recent oxygen saturation recorded as 98% (percent) on (MONTH) 16, (YEAR) at 11:03 PM. The physical assessment showed Resident #158 had no observed neurological changes but was also unresponsive, and choking. Under section summarize your observations and evaluation: Resident was eating outside food steak and cheese sandwich when he began choking. The interventions documented were 911 was called and CPR continued, resident was transported via 911. However, the eInteract Change of Condition Evaluation Form failed to show all interventions implemented to include complete vital signs, administration of oxygen, suctioning and the performance of a comprehensive assessment cardiovascular assessment, respiratory assessment, and neurological assessment at and during the change of condition. Review of the report submitted to the State Agency showed that on (MONTH) 17, (YEAR), at 9:50 PM, in the 3rd Floor Day Room, Resident #158 choked with total airway obstruction while eating a steak and cheese, and became unconscious for about one minute until airway was partial opened. According to the facility report, the [MEDICATION NAME] maneuver was performed and partial opened the airway. The staff administered oxygen via a mask and Ambu bag. Audible wheezing and sweating was observed and resident was lowered to the floor. Cardiopulmonary Resuscitation was initiated simultaneously with intermittent application of oxygen with Ambu bag. The Emergency Medical Services team arrived about three minutes after the [MEDICATION NAME] Maneuver, at which time they administered [MEDICATION NAME] and the Automated External Defibrillator was placed. Review of the facility policy titled Serenity Rapid Response Team dated (MONTH) 27, (YEAR), showed that staff are to respond to all emergencies to include a licensed nurse from each unit and the Director of Nursing/Nursing Supervisor, and Nurse Practitioner , if available. The Director of Nursing/Nursing Supervisor is responsible for bringing the AED (Automated External Defibrillator); while the other assignments are as follows: [NAME] Nurse assigned to the resident stays with the resident and directs the other staff to contact the Rapid Response Team and 911. B. Unit One Team 3 Nurse brings the Crash Cart to the scene of the emergency regardless of the location. C. Unit Two Team 3 Nurse is responsible for providing oxygen, suctioning, and ventilation with the bag valve, if necessary. D. Unit Three- Team 3 Nurse assists with placing the cardiac board under the resident and providing the compressions. During a face-to-face interview on [DATE] with Employee#26 at 4:21 PM regarding the resident's change in condition, I completed the Nursing Home to Hospital Transfer Form on [DATE] and I assisted with CPR (cardiopulmonary resuscitation) for Resident# 158. When I came in the dayroom I saw the resident trying to stick his hand down his throat , we (staff) were trying to get him to stand and he could not stand he was conscious and I was telling him to cough and Employee# 25 did the back slaps over his shoulder blades, he had cup of water he was trying to drink it and it was coming out of his mouth, then he could not breathe he was shaking and he became stiff and he was not breathing and we started CPR we called a code and 911, the supervisor (Employee# 27) came to the floor and took over CPR. During a face-to-face interview with Employee #27 on [DATE] at 5:00 PM, they called a medical emergency and I came from the first floor and I met the Resident# 158 holding his throat he said that he just choked he stood up and we supported him I did the [MEDICATION NAME] Maneuver and then we placed him on the floor and I took over CPR, oxygen and suction with a Yankeur (oral suction tool), by now 911 had arrived and his SP02 (oxygen level) was 62% they (911) took over chest compressions with an automatic chest compression system they (staff) pulled out a big piece of meat, he was alive when he left the floor he was to go (hospital name) but he went to (hospital name). During a telephone interview on [DATE], at 5:35 PM, Employee# 24, stated I was in the dayroom but I was not assigned to the resident and three residents came in with food from the outside; Resident#158 and two other residents. I was not too far away and he asked for sips of water, thickened water. While they were eating I gave him the thickened water and then I asked him if he was choking. He said yes, he only took a few bites before he started choking. It was not a long time at all, if ten minutes, before he started choking. He had a lot of sandwich left. I saw staff in the hall way and called for help they came in and started working on him. Employee #25 provided back slaps over the shoulders blades for Resident # 158's choking episode. However, backs slap are inconsistent with the [MEDICATION NAME] maneuver to address choking in adults and can further lodge food in airway. The [MEDICATION NAME] maneuver includes the performance of abdominal thrust and chest thrust to dislodge foreign object from airway. Pavitt, M. [NAME], Swanton, [MI] [MI], Hind, M., Apps, M., Polkey, M. I., Green, M., & Hopkinson, N. S. (2017). Choking on a foreign body: A physiological study of the effectiveness of abdominal thrust maneuvers to increase [MEDICATION NAME] pressure. Thorax, 72(6), 576. doi:http://dx.doi.org.contentproxy.phoenix.edu/10.1136/thoraxjnl-,[DATE] Review of personnel record showed, Employee #25 received Cardiopulmonary Resuscitation training to include the [MEDICATION NAME] maneuver. The medical record lacked documented evidence of monitoring and assessment to include the recording of physiological signs and symptoms of distress when the resident's condition declined prior to transfer to the Emergency Department. The facility's failure to assess, implement interventions, and properly intervene placed Resident #158 at harm. The facility's failure to assess, implement interventions, and properly intervene lead to Resident #158's harm and subsequent death. 2. Facility staff failed to provide treatment and care in accordance with professional standards of practice for Resident #96. Resident #96 was admitted to the facility on [DATE] (initial admitted ) with [DIAGNOSES REDACTED]. Resident interview on [DATE],8 at 3:30 PM the Resident was asked, do you have any problems with vision or hearing? Resident stated I have not had an eye appointment and they stopped giving me my eye drops for my [MEDICAL CONDITION] my vision is real blurry now. Review of the medical record on [DATE], at 9:30 AM showed a physician order dated [DATE] Ophthalmology Consultation for Resident with [MEDICAL CONDITION], [MEDICATION NAME]/[MEDICATION NAME], 0.004% eye drop 1 gtt (drop) to both eyes Q HS (every bedtime) DX (diagnosis) [MEDICAL CONDITION], Dorzolamide-[MEDICATION NAME] 2%-0.5% eye drop 1 gtt (drop) to both eyes BID (twice a day) Dx [MEDICAL CONDITION]. A further review of the medical record showed a Compressive Minimum Data Set (MDS) dated (MONTH) 15, (YEAR), Section B Hearing, Speech and Vision (B1000). Vision ability to see in adequate light (with glasses or other visual appliances), the code entered is 1 which indicates Impaired-sees large print, but not regular print in newspaper/books. (B1200) Corrective lenses (contacts, glasses or magnifying glass) used in completing (B1000), Vision the code entered is 0, which indicates no. A review of the medical record on [DATE] at 10:30 AM showed Medication Administration Record [REDACTED] The medication administration showed eye drops were administered to Resident #96 during the months of September, (YEAR) October, (YEAR) November, (YEAR) December, (YEAR) A further review of the medical record on [DATE] at 11:30 AM showed Resident # 96 Medication Administration Record [REDACTED] January (YEAR) February (YEAR) March (YEAR) April (YEAR) May (YEAR) June (YEAR) July (YEAR) However, the Medication Administration Records did not show the order for eye drops Dorzolamide HC-[MEDICATION NAME] Mal Solution 22XXX,[DATE].8 MG/ML (milligram/milliliter) one drop in both eyes two times a day for [MEDICAL CONDITION] and Dorzolamide-[MEDICATION NAME], 2%-0.5% Drops, instill 1 drop in both eyes two times a day for [MEDICAL CONDITION] was transcribed or that the Resident received the eye drops for the past seven months. During an interview on [DATE], at 12:30 PM, Employee# 4, stated I see the eye drops are not on the MAR (medication administration record) and I don't see an order to stop them, let me keep looking. During a telephone interview on [DATE], at 1:00 PM the Physician, stated the Resident had multiple hospitalization s and that is why he (Resident) may not have had the Ophthalmology Consult, and the order for eye drops check to see if the eye drops are on the discharge hospital paperwork, but I understand that he should have received the eye drop order for eye drops. During an interview with Employee #4 on [DATE], at 3:00 PM Employee stated no I could not find that the resident received the eye drops since (MONTH) of (YEAR), the Resident did go in and out of the hospital, he did not receive the eye drops at all this year. Facility staff failed to provide evidence Resident # 96 was provided care and treatment (administration of eye drops) in accordance with professional standards of care. During a face-to-face interview on [DATE], at 3:00 PM Employee# 4 acknowledged the findings at the time of the observation. A further review of the medical record on [DATE], at 10:00 AM showed a physician's order dated [DATE] Latanoprost 0.005% ophthalmic solution (eye drop) at bedtime every day and Dorzolamide HCL Solution 2% one drop twice a day every day. During a face-to-face interview on [DATE], at 10:00 AM Employee# 4 stated here is the order and again acknowledged the finding. | 2020-09-01 |