| 2 |
THE MEADOWS ON UNIVERSITY |
355024 |
1315 S UNIVERSITY DR |
FARGO |
ND |
58103 |
2017-05-10 |
309 |
D |
1 |
1 |
ZMNB11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, review of professional literature, and staff interview, the facility failed to provide the care and services necessary to attain the highest degree of safety possible for 1 of 1 sampled residents (Resident #7) requiring staff assistance with meals. Failure to provide proper positioning during/following meals, failure to cut the meats into appropriate bite sized pieces, and failure to follow the 3 cough rule as outlined by therapy, placed Resident #7 at a greater risk for aspiration. Findings include: Swigert's The Source for Dysphagia, 3rd ed., Pro-Ed, Inc., Texas, 2007, pages 9, 15, 16, 125, and educational handouts, identified, . Signs and symptoms of dysphagia . coughing/choking . left hemisphere stroke indicative of oral dismotility . [MEDICAL CONDITION] . swallowing problems . often begin with reduced tongue based retraction and repetitive tongue rolling, followed by delayed initiation of the pharyngeal swallow . head and [MEDICAL CONDITION] . [MEDICAL CONDITION] therapy can have a significant impact on pharyngeal swallowing, sometimes years after the [MEDICAL CONDITION] therapy . During the oral intake of . liquids, it is optimal for a patient to be seated at a 90 degree angle . (when) in a chair . Even a slightly reclined position while eating greatly increases the risk of premature loss of food over the back of the tongue . Review of Resident #7's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS), dated [DATE], identified long and short term memory problems, extensive assistance with meals, and extensive assistance of two for bed mobility and transfers. A Speech Therapy progress note, dated 12/26/15, stated, . She requires 1:1 feeding. Pt (patient) should be upright for all meals at least 90 degrees, straws are ok, 3 cough rule-discontinue texture if more than 3 coughs are noted and notify SLP (speech language pathologist), encourage self-feeding and monitor lungs/temps (temperatures) closely for any signs of aspiration. A current physician order, dated 04/27/17, identified, . 3 cough rule - if pt coughs with anyone item - discontinue (sic) for current meal tray & notify SLP. Patient to remain upright for a min (minimum) of 30 - 40 minutes after intake. HOB (head of bed) up at 90 degrees and alert for all P.O. (oral) intake. Resident #7's current care plan stated, . ADL (activities of daily living) . deficit as evidenced by the need for assistance related to disease process . physical limitations, visual impairment . all meals in dining room with assist of 1 for feeding . Regular diet, thin liquids, . cut up all meat, . Resident #7's current kardex also stated, . Must sit upright 30-45 minutes after meals . Observation showed the following: * On 05/09/17 at 8:10 a.m., Resident #7 sat in her reclining wheel chair in the dining room with the head of chair reclined at an approximately 35 to 45 degree angle. A CNA (#11) fed Resident #7 large pieces of sausage (approximately two inches in diameter), hash browns, toast, cream of wheat, and cranberry juice. * On 05/09/17 from 8:30 a.m. to 10:50 a.m., Resident #7 sat in her reclining wheel chair in a lounge. Her chair remained in the same position (reclined to 35 to 45 degrees). * On 05/09/17 at 10:50 a.m., after providing cares, a CNA (#3) raised the head of Resident #7's bed to an approximate 30 degree angle (which placed her at an approximate 35 degree angle with the pillow behind her head) and offered her a drink of water, which she swallowed. The CNA (#3) then lowered the head of the bed to an approximate 25 degree angle and exited the room. * On 05/09/17 at 12:05 p.m., Resident #7 sat in her reclining wheel chair in the dining room with the head of the chair reclined to an approximate 35 to 40 degree angle. A CNA (#11) fed Resident #7 pieces of roast beef, mashed potatoes and gravy, peas, bread, and apple juice. Resident #7 coughed (loose non-productive) four times during the meal. * On 05/09/17 at 12:20 p.m., Resident #7 fell asleep in her reclining wheel chair in her room. Her chair remained in the same position (reclined to 35 to 45 degrees). * On 05/10/17 at 8:45 a.m., Resident #7 laid in bed. The head of the bed remained reclined at an approximate 30 degree angle. The CNA (#12) left Resident #7 a glass of water on the table, within her reach, prior to exiting the room. Facility staff members failed to ensure Resident #7 sat at a 90 degree angle prior to offering food or fluids, failed to ensure she remained upright for at least 30 to 45 minutes after each meal, failed to cut her meats into appropriate bite sized pieces, and failed to follow the three cough rule as outlined by the SLP. During an interview on 05/10/17 at 11:35 a.m., an administrative staff member (#1) confirmed staff last assessed Resident #7's swallow ability in (YEAR). The medical record showed she was diagnosed with [REDACTED]. Facility staff failed to reassess her swallow following this last bout of aspiration pneumonia to determine if there were any additional changes to her swallowing ability. |
2020-09-01 |