| 3 |
BENEFIS SENIOR SERVICES |
275012 |
2621 15TH AVE S |
GREAT FALLS |
MT |
59405 |
2017-03-09 |
280 |
D |
0 |
1 |
KTFZ11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to follow the established plan of care for swallowing precautions and assisting with protective boots for 2 (#s 15 and 19) of 24 sampled residents. Findings include: 1. Resident #15 was readmitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. During an observation on 3/6/17 at 12:33 p.m., resident #15 was on the other side of the dining room, eating at a table independently. The resident coughed periodically. Shortly after this observation, the resident was wheeled into his room. Review of the resident's meal tray card, found in a basket in the Goodnow kitchen, showed the resident was on a quality of life diet, required finely chopped meat approximately 1/8 to 1/4 inch size bites, required one small bite with swallow, and was to be encouraged to eat at a slow rate with dining room supervision. The resident required decreased distractions during the meals. During an observation on 3/7/17 at 12:35 p.m., staff member N rushed to resident #15 who was coughing and making gurgling sounds with a reddened face. Staff member N wheeled the resident into his room and held a spit cup under his mouth while he coughed. Staff member N stated he did not cough up anything. She brought him back to the dining room. She sat with him and offered him fruit chunks which were cut up approximately 2/3 of an inch in size. The resident drank his soda and coughed more. Staff member N only asked the resident to slow doww, no other instructions were provided to the resident. The resident was not told to alternate food bites with beverage sips or to swallow between each bite of food. When asked if the resident required supervision with meals, staff member N stated He eats alone. She stated she had some extra time right now to sit with the resident. She stated the staff were to remind him to slow down. The resident had small bites of roast beef with gravy and tater tots (not 1/8th or 1/4th quarter of an inch in size bites). During an observation on 3/7/17 at 5:20 p.m., resident #15 was eating his evening meal unattended while nursing staff served other residents. He was taking large bites quickly and repeating this prior to swallowing his food. He began coughing with his face becoming reddened. At 5:25 p.m. resident continued to take quick bites while coughing. At 5:26 p.m., staff member [NAME] approached the resident and spoke with him. Resident #15 stopped eating and took a drink after the CNA redirected him. Staff member [NAME] sat with the resident and provided cues to the resident. With the CNA's supervision, the resident took less frequent bites. This continued until 5:37 p.m. and there was no further coughing. The CNA wheeled the resident away leaving the table. Review of the resident's most recent speech/swallow therapy discharge summary, dated 7/28/16, showed the following: a) Swallow Strategies/Positions: 1. Quality of life diet (regular textures of whatever the resident wanted). 2. All foods to be chopped to 1/2 inch bite sized pieces. 3. Extra gravy and sauces on foods. 4. Slow rate eating with one small bite followed by a sip of fluid. 5. Decreased distractions. 6. Dining room supervision at all times. b) Supervision for oral intake: Close supervision These instructions by the speech therapist were not observed during the aforementioned dining room observations. Review of the most recent care plan, dated 1/24/17, showed the following: 1. Small portions with seconds to avoid loading the oral cavity. 2. Encourage resident to sit at the kitchen counter for the close staff supervision. 3. Reflux precautions. 4. Staff was to remind him to eat at a slow pace with one bite of food followed by subsequent swallow. 5. Although chopped foods to 1/2 inch bite size worked in the past, the son requested food to be cut down to 1/8th or 1/4th of an inch size bites. 6. The resident had numerous choking incidents due to [MEDICAL CONDITION] structural deficits, large hiatal hernia, anxiety, paranoia and dementia. The resident refused pureed foods and thickened fluids. 7. The resident choked and the [MEDICATION NAME] maneuver was attempted on the following dates: 2/26/17, 1/16/17, 12/27/16, 10/10/16, 7/17/16, and on 7/13/16. The resident's care plan did not indicate that the resident was refusing staff's supervision during the meals with alternate methods for close supervision. During an observation of the meal service and an interview on 3/7/17 at 5:10 p.m., staff member D stated resident #15 did not like supervision or anyone sitting with him during meals. She stated he would throw his tray or food and/or quit eating. She stated he became paranoid when people watched him eat. When asked if the staff sat down and ate with him, while monitoring him and giving him instructions on his swallow precautions, she stated she did not not know. The resident was sitting alone at the table. During an interview on 3/8/17 at 8:30 a.m., staff member R stated she was very familiar with resident #15. The resident had psychological issues and quit eating if someone sat with him. She stated the resident refused pureed textures. She stated he truly needed to eat in a quiet place. She was asked if these statements were part of the resident's medical records and if so to provide it to the surveyor. As of the end of the survey on 3/9/17, no additional documentation was provided. During an interview on 3/8/17 at 3:45 p.m., staff member C stated the resident used to dislike it if staff supervised or helped him with his meals. She stated she understood that they were not really following the resident's care plan. She stated he was changing, and he did not have behaviors as before during meals. The resident declined an interview on 3/8/17 at 1:39 p.m. 2. Review of resident #19's Quarterly MDS, with an ARD of 1/27/17, showed the resident was cognitively impaired and required extensive assistance with ADLs. Review of physician orders, dated 5/29/13, showed resident #19 was to wear bilateral protective sleeves and Rooke boots (foam boots around the leg and foot) to be worn all the time. During an observation on 3/7/17 at 5:08 p.m., resident #19 was seated in a broda chair, in the Lodge dining room. The resident was wearing Rooke boots. During an interview on 3/7/17 at 5:20 p.m., staff member V stated resident #19 was to wear Rooke boots all the time, even in bed. During an observation on 3/8/17 at 4:05 p.m., resident #19 was seated in the Lodge dining room, awaiting the meal. The resident was sitting in the broda chair, wearing Rooke boots. Review of resident #19's Care Plan, with a start date of 2/1/17, showed the facility staff had not identified the need, goal, and procedure for the wearing of the bilateral protective sleeves and Rooke boots. |
2020-09-01 |