Medford Multicare Center for Living
May 2, 2018 Complaint Survey

Standard Health Citations

FF11 483.12(a)(1):FREE FROM ABUSE AND NEGLECT

REGULATION: §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must- §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 2, 2018
Corrected date: July 2, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review during an abbreviated survey (Complaint#NY 132), the facility did not ensure resident rights to be free from neglect for one of three residents reviewed for neglect (Resident #1). Specifically, the Certified Nursing Assistant (CNA #1) provided food to Resident #1 that was intended for another resident. Resident #1 had a physician order [REDACTED]. Subsequently, the resident consumed food from the tray and choked. The findings were: The Facility policy dated 6/22/2017 titled Abuse, Neglect and Mistreatment defined neglect as the failure to provide timely, consistent, safe, adequate and appropriate services, treatment, and/or care to a patient or resident of a residential health care facility while such patient or resident was under the supervision of the facility, including but not limited to nutrition, medication, therapies, sanitary clothing and surroundings and activities of daily living. The Facility policy dated 6/1/2002 titled Identification Bracelet: Residents, documented all residents in the facility would have an identifying wristband in place at all times to allow for proper resident identification. The resident (Resident #1), was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (a resident assessment tool) dated 1/13/2018 documented moderately impaired cognition for the resident. The resident required total assistance of one person for eating. The resident was fed by a feeding tube. The Comprehensive Care Plan (CCP) titled Activity of Daily Living (ADL), Functional/Rehabilitation Potential dated 9/10/2016 documented the resident required total assist for eating. The CCP dated 9/10/2016 titled Tube Feeding documented potential for alteration in tube feeding due to dysphagia. Interventions included Aspiration Precaution and tube feeding as ordered. The Resident Care Instructions (CNA plan of care) dated 1/1/2018 to 4/26/18 documented the resident required total assistance of one person for eating and was on feeding tube. The Resident Care Instructions lacked documented evidence of the NPO status for the resident. The physician's orders [REDACTED]. The Nursing Progress Note (NPN) dated 4/12/2018 at 2:55 PM by Registered Charge Nurse (RCN) documented: at 12:25 PM, RCN was speaking to the resident's roommate and observed the resident (#1) was choking. The resident's face was red. The resident was observed with a lunch tray in front of her with minimal amount of food missing; food was observed in her mouth. The resident was suctioned. The Nurse Practitioner (NP) was informed and ordered chest x-ray on that day and another chest x-ray to be obtained on 4/15/18. The Respiratory Therapy (RT) progress note dated 4/12/18 at 12:41 PM documented the resident remained on ventilator. Bilateral breath sounds were diminished with wheezing. The resident was suctioned with moderate amount of thick tan colored sputum. The facility's investigative summary dated 4/12/2018 documented at 12:25 PM the CNA (#1) was given direction by the RN (#1) to give the resident's roommate her lunch tray. The CNA failed to check the resident's identification band against the meal ticket and provided the tray to Resident #1 that was intended for another resident (Resident #1's roommate). The resident (#1) was able to consume some of the meal causing her to choke. The RT suctioned the resident's airway and oral cavity until clear. The Resident had no adverse effects; the vital signs were stable; no loss of consciousness and ventilation was resumed. The MD was informed and ordered chest x-ray that day and on 4/15/18 to rule out aspiration. The CNA (#1) was terminated. The facility concluded that there was no reasonable cause to believe any alleged abuse, mistreatment or neglect had occurred. The Registered Nurse (RN) #1 was interviewed on 4/26/2018 at 1:10 PM and stated she distributed the lunch trays on 4/12/2018. She checked all the trays by comparing the meal ticket against the meal on the tray. She checked Resident #2's (Resident #1's roommate) tray and instructed CNA #1 to set it up for Resident #2. CNA #1 took the tray and went to Resident #2's room. After approximately 3 minutes the Clinical Care Coordinator (CCC) was being summoned to the resident's room. Resident #1 was given the meal tray that was for Resident #2. The RN spoke to CNA #1 after the incident and she told her that she gave the tray to Resident #2. RN #1 stated that the CNA was expected to check the name bracelet. The RN told CNA #1 three times to give the meal tray to Resident #2 including the room number and bed. The RCN was interviewed on 4/26/2018 at 1:41 PM and stated she went in to Resident #2's room at 12:25 PM shortly after the trays were distributed to talk to Resident #2 about her medication change. The curtain was open between Resident #1 and Resident #2's beds. The RCN could not recall seeing a meal tray in front of Resident #1 at the time of her entrance to the room. During her conversation with Resident #2 the RCN observed that Resident #1's face was red and she was choking and the ventilator was alarming. The RCN noted food on the resident's lips, gown and a tray in front of her. Resident #1 was coughing and choking. The ventilator alarms sounded. RT responded to the alarms and suctioned the resident. The vital signs were stable. The resident did not lose consciousness. CNA #1 handed Resident #2's meal tray to Resident #1. CNA #1 did not know who Resident #2 was because she did not check the identification band prior to setting up the tray for the resident. The RCN stated that the resident (#1) was NPO and if she saw the meal tray when she entered the room, she would have taken it away from the resident. The RCN denied observing a meal tray in front of Resident #1 when she first entered the room. All CNAs should check the identification band of the resident to match the meal ticket prior to handing out the meal trays. The RT was interviewed on 4/26/2018 at 2:07 PM and stated she was outside the room when she heard the ventilator alarm for the resident and at the same time RCN asked her to come to the room. The RT saw Resident #1 sitting and her face and neck was red. Resident #1 was coughing, trying to spit and she appeared uncomfortable. Resident #1 was placed on 100% oxygen. A high-pressure alarm was triggered which could be due to spasm, secretions or obstruction. The RT suctioned Resident #1 with a lot of secretions but no food particles were noted. The CCC was interviewed on 4/26/2018 at 3:05 PM and stated that CNA #1 gave the meal tray to a resident who was NPO. CNA #1 told her that she did not check the resident's name bracelet. CNA #1 was interviewed on 4/26/2018 at 3:13 PM and stated that she was not assigned to Resident #1 and Resident #2. She was helping to pass the meal trays. The nurse (could not recall name) told her to give the tray to room --- bed B (Resident #1). CNA #1 went and gave the tray to --- bed B (Resident #1). CNA #1 stated she was supposed to look at the meal ticket and the resident's name band to compare the resident's name but she did not. The DON was interviewed on 4/26/2018 at 4:13 PM and stated that Resident #1 was inadvertently given the roommate's tray (Resident #2) and choked. CNA #1 admitted that she did not check Resident #1's name band. CNA #1 was assessed for her proficiency in meal service and preparation during orientation. The facility concluded that CNA #1 did not identify the resident prior to handing out the meal tray. The CNA was expected to check and identify the resident prior to providing care. CNA #1 was terminated. 415.4(b)

Plan of Correction: ApprovedJune 19, 2018

The Medford Multicare Center (MMC) for living submits that its policies, procedures and systems are in place to ensure residents are free from abuse, mistreatment, neglect, misapporpriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat. This plan of correction is required by federal and state regulations and is not to be construed as an admission that the cited deficiencies are accurate at the time of the survey the facility did not have policies, procedures and systems in place to maintain compliance with all requirements.
Corrective action(s) for resident(s) affected:
Resident #1's care instructions were revised to state resident is NPO (Nothing by mouth), resident had a CXR on 4/12/18 following the choking incident with a repeat CXR on 4/15/18.
CNA #1 was terminated from the facility
Resident #1 was identified as having an identification band in place and accurate.
The RN CCC's checked all resident's residing at MMC for proper placement and accuracy of identification bands any negative findings were immediately corrected.
Identification of residents that could be affected by the deficient practice:
All residents that are NPO or are on an altered consistency diet have the potential to be affected by the deficient practice if a resident is provided food that is intended for another resident if the resident's identification band is not verified correctly against the meal ticket.
Resident's #1's care instructions were revised to state resident is NPO. All residents with an NPO order was reviewed to ensure documented evidence is in the resident care instructions of the NPO status for the resident and was found to be compliant.
Systemic Measures to prevent recurrence:
The Policy and Procedure for Meal Distribution has been reviewed and found to be compliant.
All clinical staff, RN's, LPN's and CNA's have been educated by the Nurse Educator/Designee on the Policy and Procedure of Meal Distribution, specifically that the CNA will identify the resident by the resident's identification band against the meal ticket, verifying the correct resident with the correct meal ticket prior to preparing tray.
Ongoing Monitoring:
The DON/Designee will conduct an initial audit on 100% of the residents with an NPO order, to ensure documented evidence is in the Resident Care Instructions of the NPO status for the resident and was found to be compliant.
The CCC's/Designee will conduct an observational/visual audit on 25% of the residents during a meal to ensure compliance with identification of ID band against the meal ticket for the resident every week for one month and every three months thereafter until 100% compliance is achieved.Any negative findings will be immediately corrected.
An audit will be conducted by the ADON/Designee on any new NPO orders and any new admissions that are NPO to ensure documented evidence is in the Resident Care Instructions of the NPO status of the resident every week for one month and every three months thereafter with 100% compliance.It will be the responsibility of the Dietician to notify the ADON of any resident with an NPO status via electronic medical record.
The DNS/Designee will report findings of the audits at the monthly QAPI meeting.
Responsible Person: Director of Nursing
Completion Date: 7/02/2018