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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 10, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews during an abbreviated survey (Case #'s NY 049 and NY 977), the facility did not ensure the environment remained free of accident for 1 (Resident #1) of 1 reviewed for accident hazards. Specifically, for Resident #1, who had Nothing by Mouth (NPO) diet order was due to high risk for aspiration pneumonia was fed pizza. This is evidenced by: Policy and Procedure for nutrition and diet dated 12/13/2024, documented residents who are designated as nothing by mouth (NPO) need to be closely monitored to ensure no access to food is allowed. Resident #1 entered on 11/04/2024 with [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated 11/10/2024, documented the resident could be understood, and understand others with severely impaired cognition for decision making. The resident was nonverbal and communicated by using a communication board. The resident had recently received a gastrostomy tube after been assessed to by speech language pathologist to be at high risk for aspiration. The Comprehensive Care Plan Titled Nutrition dated 11/04/2024, documented: Resident was nothing by mouth (NPO) after failed swallowing evaluation after hospitalization for episodes of aspiration pneumonia. Insertion of j-tube prior to admission on 11/04/ 2024. Tube feeding [MEDICATION NAME] (formula) full strength via J-tube at 40 millimeter (amount delivered) per hour continuous 24-hour delivery with water flushes every 4 hours. Physician orders [REDACTED].#1 was nothing by mouth (NPO) with tube feeding [MEDICATION NAME] (formula) full strength via J-tube at 40 millimeter (amount delivered) per hour continuous 24-hour delivery. A nursing progress note dated 11/22/2024 at 3:02 PM written by Registered Nurse Unit Manager #1) documented they were notified by the medical provider (nurse practitioner) that Resident #1 had a slice of pizza. Upon arrival, resident was eating the pizza, which was given to them by another resident. Resident #1 gave this writer the rest of the pizza. They had pizza in their mouth, which was removed. They began to cough and was taken to their room, where they coughed up the pizza. The medical provider conducted an assessment and issued a new order for a chest X-ray. Additionally, vital signs and lung sounds were to be monitored every shift for the next three days. The family member was made aware. An Accident and Incident report dated 11/22/2024 at 4:06 PM, documented the resident obtained a piece of pizza without staff being aware. The resident was not allowed anything by mouth, an investigation determined the resident was given the pizza by another resident, family, and physician aware. Chest X-ray negative, vital signs stable, and Speech Language Pathologist would follow up. During interview on 12/16/2024 at 12:45 PM, Speech Language Pathologist #1 stated that they were not at the facility when the incident occurred, but they were requested to see the resident for further evaluation and another swallowing evaluation. Resident #1 swallowing evaluation determined the resident was not appropriate for oral intake and needed to remain as nothing by mouth status due to high risk for aspiration. They stated Resident #1 had a history of [REDACTED]. Resident #1 was not appropriate for anything other than tube feeding. During an interview on 12/16/2024 at 1:40 PM, Registered Nurse Manager #1 stated staff should monitor the resident closely when the resident was out in the common area and other residents were in the possession of food. They stated they did not bring residents who were on tube feedings during mealtime out but Resident #1 enjoyed being out in the area with other residents. During an interview on 12/16/2024 at 2:15 PM, Licensed Practical Nurse #1 stated Resident #1 indicated after the incident that they wanted the pizza. They had been eating before coming to the facility. There had been no indication prior to this incident that the resident would try to eat anything. They stated they monitored the resident closely and the Speech Language Pathologist recently did another swallowing evaluation for pleasure foods. During an interview on 12/16/2024 at 2:50 PM, Director of Nursing #1 stated on the day of the incident 11/22/2024, Resident #1 was sitting in the common area where the other residents have meals after lunch was over. The Nurse Practitioner was getting off the elevator and saw the resident holding a piece of pizza and chewing on a piece of the pizza. The pizza was taken away from the resident and attempts to get the resident to spit out the piece they were chewing. The resident was taken to their room and the suction machine in the resident's room was used to clear the resident ' s mouth. No signs or symptom of aspiration was noted but a chest X-ray was ordered to ensure the resident had not aspirated on the food. They stated the resident was new to the facility and had recently had an insertion of a feeding tube due to aspiration pneumonia and a failed swallowing evaluation. The resident was nothing by mouth (NPO) and was receiving all nutrition through the tube. The x-ray was done, and no signs of aspiration and interventions was added to the resident comprehensive care plan. 10 New York Codes, Rules and Regulations 415. 12(h)(2) | Plan of Correction: ApprovedMarch 7, 2025 What corrective actions were taken for the affected resident: 1. Resident #1 suffered no ill effect from receiving pizza from another resident. Resident #1 was assessed by the Nurse Practitioner and chest radiograph was negative for aspiration pneumonia. Care plan was reviewed and revised. How will you identify others at risk to be affected by the alleged deficient practice: 1. A review on 2/12/2025 of current diet orders reveals no other residents have order for Nothing By Mouth. 2. Diet orders will be reviewed on all new admissions to identify residents with Nothing By Mouth status placing them at risk to be affected. Those at risk will be care planned appropriately. What measures will be put in place or what systemic changes you will make to ensure that the alleged deficient practice does not recur: 1. All staff were educated on ?ôSpecial Considerations for the Resident who is Nothing By Mouth.?Ø 2. The facility will continue to educate all staff on ?ôSpecial Considerations for the Resident who is Nothing By Mouth.?Ø on hire and annually. How the corrective action(s) will be monitored to ensure the deficient practice will not recur: 1. Nursing staff will conduct weekly audits of activities and/or dining to ensure residents with NPO orders are not present while food is being served. Audits will be conducted on various shifts weekly for four (4) weeks then monthly for two (2) months. Audit results will be forwarded to the Quality Assurance Process Improvement Committee for review and further recommendation. Responsibility: Director of Nursing or Designee |