Chestnut Ridge Health & Rehabilitation

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement a comprehensive, individualized care plan that accurately reflected the nutritional and dietary needs of a resident with a history of swallowing disorders. The resident had previously experienced choking incidents and had been evaluated by a Speech-Language Pathologist (SLP), who recommended a pureed diet with nectar thick liquids and specifically advised against peanut butter sandwiches. Despite these recommendations and physician orders, the resident's care plan did not include specific interventions to ensure that all snacks provided, including those outside of scheduled meals, met the prescribed therapeutic diet. On the day of the incident, a Certified Nurse Aide (CNA) provided the resident with a peanut butter sandwich at the resident's request, despite being aware of the pureed diet order. The CNA had previously observed the resident eating peanut butter sandwiches without difficulty and did not verify the current diet order through available resources such as the KARDEX, electronic medical record, or by consulting a nurse. The resident choked on the sandwich, became unresponsive, and later died at the hospital. The official cause of death was determined to be choking on a food bolus. Interviews with staff revealed a lack of clarity and consistency in care planning and implementation. The care plan did not incorporate the SLP's or dietary manager's recommendations, and there was no policy or standard provided regarding acceptable food items for different therapeutic diets. Staff members were aware of the resident's dietary restrictions, but the absence of clear, individualized interventions in the care plan contributed to the provision of an unsafe snack, resulting in the resident's death.

Removal Plan

• The Dietary Manager labeled all snacks/snack-room foods with correct consistency per residents' diet orders.
• The DON, ADON, and SDC educated all licensed nurses, CMTs, and CNAs regarding: Reviewing the care plan, KARDEX, and diet orders before providing snacks; IDDSI standards for puree and mechanical soft diets; Specific instruction that peanut butter was not allowed for puree diets unless blended with another food to meet puree consistency.
• Staff completed return demonstrations and will not work unsupervised until competency verified.
• Care plans for all residents on modified diets were reviewed and updated by licensed staff to include: Speech therapist and dietary recommendations; Specific snack and supplemental food interventions; Cross-reference to diet order consistency requirements.
• Administrator initiated ongoing daily audits of snacks and care plans to ensure compliance.
• New staff will be educated during orientation and before working independently.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A facility failed to ensure that a resident received a therapeutic diet as ordered by the physician, resulting in a fatal choking incident. The resident, who had a history of cerebrovascular disease, anoxic brain damage, dementia, dysphagia, and other significant medical conditions, was prescribed a pureed diet with nectar-thickened liquids due to severe swallowing difficulties. Despite these orders, a Certified Nurse Assistant (CNA) provided the resident with a peanut butter sandwich, which was not permitted on the prescribed diet. The CNA was aware of the resident's dietary restrictions but gave the sandwich at the resident's request, having previously observed the resident eat similar food without apparent difficulty. The incident occurred when the resident began eating the peanut butter sandwich and subsequently choked, leading to a loss of pulse. Staff attempted the Heimlich maneuver and initiated CPR, but the resident was ultimately transferred to a hospital and expired. The official cause of death was listed as choking on a food bolus. Interviews with staff confirmed that the CNA did not verify the resident's current diet order through available resources such as the KARDEX, care plan, or by consulting a nurse, despite being aware of the resident's dietary restrictions and the facility's protocols for verifying diet orders before providing snacks. Further review revealed that the facility's policies required snacks to be compatible with therapeutic diets and that staff were trained to check diet orders before providing food to residents. However, there was no specific policy or standard provided regarding acceptable food items for different therapeutic diets. The resident had a documented history of swallowing disorders and previous choking incidents, including a prior event involving a peanut butter sandwich that led to a change in diet orders and additional speech therapy interventions. Despite these measures, the failure to follow the prescribed diet directly resulted in the resident's death.

Removal Plan

• All mechanical soft and pureed snacks in the snack room and refrigerator were labeled by the Dietary Manager with the appropriate consistency.
• The Administrator reviewed all snacks and supplemental foods available outside of meal service to ensure compliance with current diet orders.
• Education was initiated by the Director of Nursing, Assistant Director of Nursing, and Staff Development Coordinator for all licensed nurses, certified medication technicians, and certified nurse aides.
• Staff were instructed on the new process for labeled snacks, the requirement to verify diet orders through the Kardex, care plan, or physicians' order, and the inappropriateness of peanut butter on a pureed diet unless blended to proper consistency under IDDSI standards.
• All staff completed return demonstrations prior to working their next scheduled shifts, and competency validation was confirmed.
• A 100% audit of all resident diet orders and Kardex entries was completed by the DON, MDS nurse, and Regional Nurse.
• The ADON completed a 100% audit of all physician diet orders in Point-Click-Care against tray tickets to ensure accuracy.
• Ongoing monitoring was implemented, including nursing audits of 10 trays per week for four weeks, followed by 10 trays monthly for three months.
• The Administrator audited snacks three times per week for four weeks, then decreased frequency over the following two months.
• All new hires will receive training on therapeutic diets, Kardex review, and snack verification during orientation prior to assuming care responsibilities.
• The QAPI Committee held an ad hoc meeting to review corrective actions, with a monthly follow-up scheduled for three months.
• The Medical Director was notified of all corrective measures and ongoing monitoring efforts and agreed with the plan.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to complete all required pre-employment checks for two of eight sampled new employees, specifically a Dietary Aide and an Activities Assistant. According to the facility's abuse prevention policy, all potential employees are to be screened for a history of abuse, neglect, or mistreatment, including checks of multi-state registries and license verifications. However, review of the personnel files revealed that the Kentucky Nurse Aide Abuse Registry check was not completed for either the Dietary Aide or the Activities Assistant prior to their employment. During an interview, the Administrator confirmed that while license verifications were performed for clinical staff such as CNAs and nurses, the registry check was not conducted for non-clinical staff, as they did not possess licenses to verify. The absence of a dedicated Human Resources staff member at the time contributed to this oversight.