| 19 |
BENEFIS SENIOR SERVICES |
275012 |
2621 15TH AVE S |
GREAT FALLS |
MT |
59405 |
2019-07-11 |
657 |
D |
0 |
1 |
01HJ11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess and update a resident's care plan for monitoring risks and interventions following a choking accident for 1 (#89) of 42 sampled residents. Findings include: During an observation on 7/8/19 at 4:50 p.m., resident #89 was eating alone in the back corner of the dining room. With a bedside table in front of him, a drink, and two bowls of pureed food. No staff were assisting or directly supervising to provide encouragement, or redirect the resident on alternating bites and sips, and to monitor for choking. During an observation and interview on 7/10/19 at 2:40 p.m., staff member L showed resident #89's diet card with 1:1 for dining. She stated the staff assisting meals may have missed the 1:1 for dining because the yellow post-it was covering the information. During an observation on 7/11/19 at 9:10 a.m., resident #89 was sitting alone eating breakfast in the back corner at the bedside table with three bowls of pureed food, and a drink for breakfast. No staff were assisting or providing 1:1 supervision to encourage alternating bites or sips, or to monitor for choking. Record review of resident #89's nursing note and an alert, dated 7/4/19, which showed resident #89 had a choking incident in which he turned blue and had to be given the [MEDICATION NAME] Maneuver. Record review of resident #89's Nutritional Status care plan, with a start date of 7/8/19, showed, Monitor for chewing and/or swallowing difficulties, . encourage small bites and sips alternated, .staff to assist if needed to eat. The 1:1 for dining was not on resident #89's care plan. Record review of resident #89's diet order card showed 1:1 for dining. Record review of resident #89's speech therapy notes, dated 7/8/19, showed precautions of 1:1 supervision. The skilled instruction category showed, ST discussed pt's recent choking episode with staff. Staff indicated pt. consumed a large bite of pureed solids. ST provided pt. with skilled education regarding safe swallowing strategies including small bites/sips. (sic) Record review of an Alert, dated 7/10/19 at 3:14 p.m., for resident #89 showed, Due to recent aspiration/choking events, ST recommends (#89) receive 1:1 supervision in dining room during meals. Record reveiw of the facility policy titled, Initial Nursing Assessment and Development of Interdisciplinary Resident Care Plans showed, The interdisciplinary care team, physicians, licensed nursing staff, Social Services, Activities, Physical Therapy, Occupational Therapy, Speech Pathology, Pharmac, and licensed nutrtion staff are responsible for entering additions or changes to the care plan as the condition of the resident changes.Changes in conditions are reported to the provider and resident/family member/PO[NAME] |
2020-09-01 |