PRINTED: 03/26/2020 DEPARTMENT OF HEALTH AND …

A. BUILDING ______________________

(X1) PROVIDER/SUPPLIER/CLIA

IDENTIFICATION NUMBER:

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION

(X3) DATE SURVEY

COMPLETED

PRINTED: 03/26/2020FORM APPROVED

(X2) MULTIPLE CONSTRUCTION

B. WING _____________________________

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

315506 07/02/2019

C

STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER

378 FRIES MILL ROADMANORCARE HEALTH SERVICES-WASHINGTON TOWNSHIP

SEWELL, NJ 08080

PROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATE

DEFICIENCY)

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SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

F 000 INITIAL COMMENTS F 000

COMPLAINT#: NJ 124030, NJ 124644

CENSUS: 102

SAMPLE SIZE: 4

F689 IJ

Based on interviews, Medical Record (MR)

review, and review of other pertinent facility

documents on 6/13/19 and 7/2/19, it was

determined that the facility nursing staff failed to

provide a safe environment during meal time for

Resident #3, a resident with a known history of

) and

precautions. The nursing staff failed to follow the

facility's own policies titled "Meal Service," and

"Requirements and Guidelines for Clinical

Content." In addition, the nursing staff failed to

provide and a licensed

nursing staff to monitor the dining room for 1 of 3

sampled resident (Resident #3) reviewed for

.

On , Resident #3 experienced a

episode which resulted in the

Resident's diet being downgraded from a

t texture to a and

the being discontinued

(D/C'd) without a Physician's Order (PO) by the

Registered Nurse (RN). Therefore, no

or presence of a licensed

nurse in the dining room occurred during the

dinner meal on , when Resident #3 was

served and eating dinner in the dining room,

which resulted in the Resident and

experiencing requiring

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

08/07/2019Electronically Signed

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that

other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days

following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14

days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued

program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete LGHZ11Event ID: Facility ID: NJ08004 If continuation sheet of 21

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F 000 Continued From page 1 F 000

Resident #3 to be sent out 911 to the Emergency

Room (ER). This placed Resident #3 in an

Immediate Jeopardy (IJ) situation. This IJ ran

from 4/3/19 at 2:51 p.m., through 4/21/19 at 5:55

p.m., when the Resident experienced

and distress. Resident #3 was

admitted to the hospital with

, and subsequently

admitted to the Unit with

and . This IJ

was identified and reported to the Administrator

and the Director of Nursing (DON) on 7/2/19 at

6:47 p.m., and was lifted that same day at 9:37

p.m., when the facility provided an acceptable

removal plan.

F 656

SS=D

Develop/Implement Comprehensive Care Plan

CFR(s): 483.21(b)(1)

§483.21(b) Comprehensive Care Plans

§483.21(b)(1) The facility must develop and

implement a comprehensive person-centered

care plan for each resident, consistent with the

resident rights set forth at §483.10(c)(2) and

§483.10(c)(3), that includes measurable

objectives and timeframes to meet a resident's

medical, nursing, and mental and psychosocial

needs that are identified in the comprehensive

assessment. The comprehensive care plan must

describe the following -

(i) The services that are to be furnished to attain

or maintain the resident's highest practicable

physical, mental, and psychosocial well-being as

required under §483.24, §483.25 or §483.40; and

(ii) Any services that would otherwise be required

under §483.24, §483.25 or §483.40 but are not

provided due to the resident's exercise of rights

under §483.10, including the right to refuse

treatment under §483.10(c)(6).

F 656 9/5/19


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(iii) Any specialized services or specialized

rehabilitative services the nursing facility will

provide as a result of PASARR

recommendations. If a facility disagrees with the

findings of the PASARR, it must indicate its

rationale in the resident's medical record.

(iv)In consultation with the resident and the

resident's representative(s)-

(A) The resident's goals for admission and

desired outcomes.

(B) The resident's preference and potential for

future discharge. Facilities must document

whether the resident's desire to return to the

community was assessed and any referrals to

local contact agencies and/or other appropriate

entities, for this purpose.

(C) Discharge plans in the comprehensive care

plan, as appropriate, in accordance with the

requirements set forth in paragraph (c) of this

section.

This REQUIREMENT is not met as evidenced

by:

C #NJ 124644



documents on 7/2/19, it was determined that the

facility staff failed to update and/or revise a

Resident's Care Plan (CP) timely after a fall as

well as failed to follow the facility's policy titled

"Interdisciplinary Care Planning." for 1 of 3

sampled residents (Resident #3) reviewed for

falls. This deficient practice was evidenced by

the following:

1. According to Resident #3's "Admission Record

Report," the Resident was admitted to the facility

on , with diagnoses which included but

were not limited to: ,

HOW THE CORRECTIVE ACTION WILL

BE ACCOMPLISHED FOR THOSE

RESIDENTS FOUND TO BE AFFECTED

BY THE DEFICIENT PRACTICE:

It was identified that the facility staff failed

to update and/or revise a Resident's Care

Plan timely after a fall as well as failed to

follow the facility's policy titled

"Interdisciplinary Care Planning" for

resident #3. Resident #3 no longer

resides in the facility.

HOW THE FACILITY WILL IDENTIFY

THE OTHER RESIDNETS HAVING THE

POTENTIAL OF BEING AFFECTED BY

THE SAME DEFICIENT PRACTICE:


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According to the Minimum Data Set (MDS), an

assessment tool dated Resident #3 had

memory problems and was

impaired. The MDS also indicated Resident #3

needed extensive assistance with Activities of

Daily Living (ADLs).

Review of Resident #3's "Admission/Readmission

Screen" dated , under "Baseline care plan

related to falls" showed the Resident was at risk

for falls due to and

. Interventions included the

following:

Encourage to transfer and change positions

slowly. Have commonly used articles within easy

reach. Reinforce need to call for assistance.

Review of Resident #3's 'Incident Reports" were

as follows:

On the Resident had a fall while "he/she

was attempting to stand up when his/her

pushed on the footboard and it became

loose and this caused him/her to slide to the

floor.... "

On 9, the Resident "was seen crawling on

the floor in front of his/her chair...."

Review of Resident #3's CP initiated dated

, indicated the Resident was at risk for falls

due to , decreased mobility, lack of

safety awareness secondary to

. Further review of

Resident #3's CP showed no evidence that the

CP was updated with new interventions after the

and falls.

All residents have the potential to be

affected by this deficient practice.

WHAT MEASURES WILL BE PUT IN

PLACE OR SYSTEMATIC CHANGES

MADE TO ENSURE DEFICIENT

PRACTICE WILL NOT RECUR:

Incident Management review to verify that

those resident's that have sustained a fall

within the last 30 days to validate care

plan reviewed and new care plan

interventions are in place. Review was

completed on 8/5/19.

DON/Designee will provide education to

all licensed nursing staff regarding

comprehensive care plans and post fall

assessment tool.

HOW WILL THE FACILITY MONITOR

ITS CORRECTIVE ACTION TO ENSURE

THAT THE DEFICIENT PRACTICE IS

BEING CORRECTED AND WILL NOT

RECUR, I.E. WHAT PROGRAMS WILL

BE PUT IN PLACE TO MONITOR THE

CONTINUED EFFECTIVENESS OF THE

SYSTEMIC CHANGE.

DON/Designee will review the Incident

Management-Falls to ensure that care

plans are viewed and new interventions

have been updated post fall weekly x 4

then monthly x 2.

The QAPI Committee will meet monthly x

3 months and determine further actions

and audits based on trend and analysis.


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During an interview with the Registered Nurse

(RN #1), on 6/13/19 at 2:00 p.m., the RN stated

that "falls should be updated on the CP."

During an interview with the Unit Manager (UM),

on 7/2/19 at 4:00 p.m., the UM stated, "the CP is

updated after each fall with a new intervention, if

the CP is not updated the Resident could

potentially have another fall."

During an interview on 7/2/19 at 4:30 p.m., the

Director of Nursing (DON) stated "after a fall the

CP should be updated with new interventions." In

addition, the DON indicated Resident #3's "falls

had no new interventions put in place."

Review of the facility's policy titled

"Interdisciplinary Care Planning" dated 3/18,

indicated the following:

Under "Care Planning Process-Evaluation:" As

the care plan is implemented, members of the

disciplinary team need to evaluate whether the

interventions are effective or whether the care

plan needs to be revised. Evaluating the

effectiveness of care plan interventions will help

the interdisciplinary team modify the care plan as

needed to help the patient reach their highest

practicable level of wellbeing.

Under "Care Plan Components" Interventions

identify specific, individualized elements of care,

provided by staff which help patients achieve their

goals. Interventions are the instructions for

delivering patient care and allow for continuity of

care by staff.

Evaluation may result in: Identifying factors

affecting progress toward achieving goals,

defining or redefining a patient's prognosis and

adjusting treatment plans or interventions.


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N.J.A.C 8:39-11.2(h)

F 658

SS=D

Services Provided Meet Professional Standards

CFR(s): 483.21(b)(3)(i)

§483.21(b)(3) Comprehensive Care Plans

The services provided or arranged by the facility,

as outlined by the comprehensive care plan,

must-

(i) Meet professional standards of quality.


by:

F 658 9/5/19

C NJ# 124644





follow acceptable standards of clinical practice in

accordance with the New Jersey Statutes, when

the nursing staff discontinued a 1:1 supervised

feeding without a Physician's Order (PO's), and

failed to document assessments

after a fall, as well as follow the facility's own

policies titled

Evaluation," and "Requirements and Guidelines

for Clinical Content," for 1 of 3 sampled residents

(Resident #3) reviewed for PO's and

documentation. This deficient practice was

evidenced by the following:

Reference: New Jersey Statutes, Annotated Title

45, Chapter 11. Nursing Board The nurse

practice act for the State of New Jersey states;

"The practice of nursing as a registered

professional nurse is defined as diagnosing and

treating human responses to actual or potential





It was identified that the facility nursing

staff discontinued a 1:1 supervised

feeding without a Physician's order and

failed to document

assessments after a fall for resident #3.

Resident # 3 no longer resides in the

facility.


OTHER RESIDENTS HAVING THE






PLACE OR SYSTEMATIC CHANGES

MADE TO ENSURE THAT THE

DEFICIENT PRACTICE WILL NOT


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physical and emotional health problems, through

such services as case finding, health teaching,

health counseling, and provision of care

supportive to or restorative of life and wellbeing,

and executing medical regimens as prescribed by

a licensed or otherwise legally authorized

physician or dentist."

Reference: New Jersey Statutes Annotated, Title

45, Chapter 11. Nursing Board. The Nurse

Practice Act for the State of New Jersey states:

The practice of nursing as a licensed practical

nurse is defined as performing tasks and

responsibilities within the framework of case

finding; reinforcing the patient and family teaching

program through health teaching, health

counseling and provision of supportive and

restorative care, under the direction of a

registered nurse or licensed or otherwise legally

authorized physician or dentist."




were not limited to:


assessment tool dated Resident #3 had

memory problems and was



Daily Living (ADLs) and eating.

Review of Resident #3's Care Plan (CP) dated

, Under "Focus:" Activity of Daily Living

(ADL) self-care deficit as evidenced by

related to a

RECUR:

Diet orders for residents were reviewed to

ensure the orders accurately reflect the

patient's eating needs. Diet order review

was completed on 7/2/2019.

Incident Management fall log reviewed for

those residents that have sustained a fall

within the last 30 days to validate care

plan updated with new interventions,

Kardex updated and completion of the

evaluation flow sheet as per

policy. Audit was completed on 8/5/2019.

DON/Designee will provide education to

all licensed nursing staff regarding

complete, accurate transcription of the

physician orders, and 24-hour chart check

process, comprehensive care plans, post

fall assessment tool, neurological

evaluation flow sheet and updating the

resident Kardex per policy.

HOW THE FACILITY WILL MONITOR


THAT THE DEFICIENT PRACTICE IS

BEING CORRECTED AND WILL NOT

RECUR, I.E. WHAT PROGRAMS WILL

BE PUT IN PLACE TO MONITOR THE

CONTINUED EFFECTIVENESS OF THE

SYSTEMATIC CHANGE:

DON/Designee will review resident falls to

ensure that care plan interventions are

updated, evaluation flow

sheet is completed and Kardex updated


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Under "Goal:" Will receive assistance necessary

to meet ADL needs. Under "Interventions:" Assist

with daily hygiene, grooming, dressing, oral care

and eating as needed.

Review of a facility's document titled "Physician

Order Speech-Language Pathology" dated

, showed Resident #3 had a diagnosis of

Phase with

recommendations for for

lunch and dinner in the dining room. In addition,

the document showed recommendations for

precautions and strict oral care.

Review of Resident #3's Speech Therapy (ST)

"Treatment Encounter Note(s)" dated

showed under "Precautions:" Falls,

liquids,

soft diet,

precautions." In addition, under "Skilled

Instruction:" Patient and caregiver training:

Instructed patient in safe swallow strategies

specifically, small single sips and second follow

up swallow (patient unable to complete this

strategy despite max cueing) ...."

Review of Resident #3's Kardex (a quick

reference guide used by nursing staff to identify

resident's needs) and CP showed no

documentation that the Resident was on

.

Review of Resident #3's "Progress Notes (PN)"

dated at 2:51 p.m., revealed Resident #3

was noted during lunch with

food. The PN also indicated that the Resident

post fall weekly x 4 then monthly x 2.


3 months to determine further actions and

audits based on trend and analysis.


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was on diet and the diet was

changed to a diet.

Review of Resident #3's "Order Recap Report

(ORR)" dated through , revealed

that on Resident #3's order for

) Controlled diet

texture, consistency,

lunch and dinner in dining

room dated , was discontinued (D/C) on

and diet

texture, consistency was ordered. The

ORR did not show that the

was reordered.

During an interview with Resident #3's Physician,

on 7/2/19 at 4:05 p.m., the Physician stated, "I

think the D/C'd was a

transcription error." In addition, the Physician

explained "I do not think that

would have stopped a piece of food going down

the . Speech Therapy (ST) often writes

because of safety issues." The

physician further stated, "there should be a

licensed nurse in the dining room in case of an

emergency."

During an interview on 7/2/19 at 5:35 p.m., RN #3

identified as the nurse who D/C'd the order,

stated that there was no doctor in the facility that

would discontinue a for a resident

with . In addition, RN #3

stated Resident #3 has always been on

with meals, if Resident #3 was not

supervised the Resident could . The RN

further stated, "I do not recall taking the order to

D/C ."

Review of Resident #3's CP initiated dated


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indicated the Resident was at risk for falls

due to , decreased mobility, lack of

safety awareness secondary to

. Further review of

Resident #3's CP showed no evidence that the

CP was updated with new interventions after the

and falls.

Review of the facility's "Incident Report," revealed

Resident #3, had several falls as follows:

On the (resident) patient was crawling in

front of Geri-chair and did not appear to be in

pain or hurt. Patient denies .

When asked what happened, patient said, "I don't

know." Patient had nonskid socks on at the time.

Lighting was ample, Medical Doctor (MD) and

family made aware. checks

and vital signs were initiated.

According to the 'Investigation Report" under

"Documents Reviewed" the care plan was

reviewed but not updated.

On under "Incident Description and

Investigation" the resident was found lying on

his/her left side of the floor. Under "Summary of

Alleged Incident" indicated "the CNA was doing

care for (Resident #3) when he/she fell and

landed on his/her and

vital signs were initiated. Further review of the

"Investigation Report" under "Documents

Reviewed" indicated the care plan was reviewed.

No indication that the care plan was updated

and/or revised.

On , under "Incident Description and

Investigation" the resident was found sitting on

the floor at the nurses' station.... Patient's vital

signs and initiated. Under

"Documents Reviewed" indicated the care plan


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was reviewed. No indication that the care plan

was updated and/or revised.

Review of Resident #3's " Evaluation

Flow Sheet )" revealed blanks which

indicated the Resident l assessments

were not completed as follows:

On 3/6/19 at 3:30 p.m. and 11:30 p.m.

On 3/8/19 and 3/9/19 at 12:20 a.m.

On 3/9/19 at 8:20 a.m. and 4:20 p.m.

Further review of the under "

Movement Evaluation," showed no

documentation as have been done.

On 3/13/19 at 11:30 p.m.

On 3/14/19 and 3/15/19 at 7:30 a.m.

On 3/17/19 at 3:30 p.m.

On 3/18/19 at 11:30 p.m.


Registered Nurse (RN) stated "the purpose of

is for changes in ,

and . A change in

could be missed if not done." The RN

further stated "a blank means they forgot to

document or they didn't do it. If it's not

documented it wasn't done."


Unit Manager (UM) stated "if the Resident fell on

the floor, we would do an assessment including,

, and ." The UM further

stated "if are not completely filled

out, potentially you could miss a deficit."

During an interview on 7/2/19 at 4:30 p.m., with

the Director of Nursing (DON), the DON stated

"an unwitnessed fall would require

to be done."


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Review of a facility's policy titled "Requirements

and Guidelines for Clinical Content," dated 2017,

revealed the following:

Under "Transcription or Noting Orders:" included

"Physician orders that are written, telephone or

faxed are noted by a licensed nurse. The nurse

is responsible for the accuracy of transcription...."

Review of the facility's policy titled "Neurological:

Evaluation" dated 3/2010 revealed

the following:

Under "Purpose": A evaluation is

used to establish a baseline status

upon which subsequent evaluations may be

compared and changes in status

may be determined.

Under "Use": Following a witnessed fall (when a

patient has hit his/her head), Following an

un-witnessed fall (when a head injury may be

suspected), Following a patient event which

results in a known or suspected head injury (i.e.:

hemorrhagic stroke).

Under "Procedure" #4. After the completion of

initial evaluation with vital signs,

continue evaluations every 30-minutes x 4, then

every 1 hour x 4, then every 8-hours x 9 (for the

next 72-hours).








N.J.A.C: 8:39-11.2 (b)


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N.J.A.C: 8:39-27.1(a)

F 689

SS=J

Free of Accident Hazards/Supervision/Devices

CFR(s): 483.25(d)(1)(2)

§483.25(d) Accidents.

The facility must ensure that -

§483.25(d)(1) The resident environment remains

as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate

supervision and assistance devices to prevent

accidents.


by:

F 689 8/2/19

C#: NJ 124644





provide a safe environment during meal time for

Resident #3, a resident with a known history of

The nursing staff failed to follow the

facility's own policies titled

Management, Meal Service," and "Requirements

and Guidelines for Clinical Content." In addition,

the nursing staff failed to provide

and a licensed nursing staff to monitor

the dining room for 1 of 3 sampled resident

(Resident #3) reviewed for

On Resident #3 experienced a

episode which resulted in the

Resident's diet being downgraded from a

texture to a and

the being discontinued





It was identified that the facility nursing

staff failed to provide a safe environment

during meal time for resident # 3 by failing

to provide 1:1 supervised feeding.

Resident # 3 no longer resides in the

facility.


OTHER RESIDENTS HAVING THE






PLACT OR SYSTEMATIC CHANGES

MADE TO ENSURE THAT THE

DEFICIENT PRACTICE WILL NOT


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(D/C'd) without a Physician's Order (PO) by the

Registered Nurse (RN). Therefore, no 1

or presence of a licensed

nurse in the dining room occurred during the

dinner meal on when Resident #3 was

served and eating dinner in the dining room,

which resulted in the Resident and

experiencing requiring

Resident #3 to be sent out 911 to the Emergency

Room (ER). This placed Resident #3 in an

Immediate Jeopardy (IJ) situation. This IJ ran

from 4/3/19 at 2:51 p.m., through 4/21/19 at 5:55

p.m., when the Resident experienced

and . Resident #3 was

admitted to the hospital with

, placed on a and subsequently

admitted to the with

and This IJ

was identified and reported to the Administrator

and the Director of Nursing (DON) on 7/2/19 at

6:47 p.m., and was lifted that same day at 9:37

p.m., when the facility provided an acceptable

removal plan. This deficient practice was

evidenced by the following:




were not limited to:


assessment tool dated , Resident #3 had

and was



Daily Living (ADLs) as well as extensive

RECUR:

On 7/2/19, the facility initiated reviews of

resident's diet orders to ensure the orders

accurately reflect the patient's eating

needs.

The facility educated nursing staff in

facility on 7/2/19 at 2045 regarding

complete, accurate transcription of

Physician's orders and the 24-hour chart

check process.

Phone calls were initiated on 7/2/19 at

2100 to nursing staff not currently in the

facility to inform them of education being

conducted in the facility and the need to

come to the center. Those nurses are

being educated by phone and notified to

obtain live training upon return to their first

scheduled shift. Education will be

ongoing for any staff that did not attend

the education prior to working next

scheduled shift. Live in person education

was completed in full 8/2/2019.

HOW THE FACILITY WILL MONITOR


THE DEFICIENT PRACTICE IS BEING

CORRECTED AND WILL NOT RECUR,

I.E. WHAT PROGRAMS WILL BE PUT IN

PLACE TO MONITOR THE CONTINUED

EFFECTIVENESS OF THE

SYSTEMATIC CHANGE:

DON/Designee will randomly audit

resident orders to ensure proper

transcription daily x 5, weekly x 3 then

monthly x 2.


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assistance with one-person physical assist for

eating.

Review of Resident #3's Care Plan (CP) dated

3/24/19, Under "Focus:" Activity of Daily Living

(ADL) self-care deficit as evidenced by

related to a

Under "Goal:" Will receive assistance necessary

to meet ADL needs. Under "Interventions:" Assist

with daily hygiene, grooming, dressing, oral care

and eating as needed.

Review of a facility's document titled "Physician

Order Speech-Language Pathology" dated

, showed Resident #3 had a diagnosis of

Phase with

recommendations for for

lunch and dinner in the dining room. In addition,

the document showed recommendations for

and strict oral care.

Review of Resident #3's Speech Therapy (ST)

"Treatment Encounter Note(s)" dated ,

showed under "Precautions:" Falls,

liquids,

soft diet,

precautions." In addition, under "Skilled

Instruction:" Patient and caregiver training:

Instructed patient in safe swallow strategies

specifically, small single sips and second follow

up swallow (patient unable to complete this

strategy despite max cueing) ...."

Review of Resident #3's Kardex (a quick

reference guide used by the CNA's to identify

resident's needs) and CP showed no


3 months and determine further actions

and audits based on the trend and

analysis.


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documentation that the Resident was on

Review of Resident #3's "Progress Notes (PN)"

dated at 2:51 p.m., revealed Resident #3

was noted during lunch with

food. The PN also indicated that the Resident

was on diet and the diet was

changed to a diet.

Review of Resident #3's "Order Recap Report

(ORR)" dated through , revealed

that on 4/3/19, Resident #3's order for

Controlled diet

texture, consistency, 1

lunch and dinner in dining

room dated , was discontinued (D/C) on

and diet

texture, consistency was ordered. The

ORR did not show that the

was reordered.

Review of a facility document titled "Incident

Report (IR) -Patient Involved" dated at

8:29 p.m., under "Incident Description and

Investigation" documented by the Registered

Nurse (RN #1) revealed that at approximately

5:00 p.m., while doing the medication pass, the

nurse was notified that Resident #3 was

in the dining room and could not stop. RN #1

also documented that that the resident was

administered

and ), an instrument

to

was between In addition, the

documentation showed the Resident's vital signs

were as follows 1 ,

The RN

further indicated that the Resident was


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without success, the Medical Doctor (MD) was

notified at approximately 5:30 p.m., 911 was

called immediately for , and

the Resident was in route to the Hospital

Emergency Room (ER) at approximately 5:55

p.m.

Review of a "Phone Interview Statement" form

dated and untimed documented by the

Assistant Director of Nursing (ADON), revealed

CNA #1 was assigned to the dining room for

dinner. According to the statement CNA #1 was

cutting meat for another resident, saw Resident

#3 starting to eat applesauce and carrots and

went over to help . In addition, CNA #1 fed

Resident #3 a little bit and Resident #3 started

. The statement also revealed that the

nurse was not in the dining room, and CNA #1

asked another CNA to get the nurse.

Review of a written statement by CNA #1 dated

at 8:29 p.m., the CNA wrote he/she was

in the dining room and dinner was being served

at 5:15 p.m. In addition, CNA #1 explained that

he/she was cutting up another resident's food and

Resident #3 started to feed himself/herself

pureed carrots and applesauce. CNA #1 then

went over to feed Resident #3 a little mashed

potato and Resident #3 started coughing, the

nurse was called and RN #1 responded. CNA #1

also wrote "I was the only one in the D.R. (dining

room)."

Review of a "Verbal Witness Statement" dated

at 8:30 a.m., given by the Dietary Aide

(DA) revealed that on , at approximately

5:00 p.m., Resident #3 was served a diet

with liquids by the DA. According to

the statement the DA stated, "that there was only


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one CNA (Certified Nurse's Aide) in the dining

room at this time."

Review of Resident #3's PN dated at 9:41

p.m., written by RN #1, revealed that while

administering medication the nurse was notified

that Resident #3 "was coughing in the dining

room and could not stop." In addition, the PN

indicated the nurse responded and assessed the

resident, the resident was still with

, and was .

Also, the doctor was notified, and 911 was called

and the resident was sent out to the hospital.

During an interview on 6/13/19 at 12:33 p.m., RN

#4 stated residents in the assisted dining room

either need or an atmosphere where

they have others to eat with. In addition, the RN

stated, "there always has to be a nurse in the

dining room at all times during meals."


ST stated Resident #3 "was an due

to a history of ." The Resident was

, and needed a lot of cueing.

The Resident would swallow but was unable to

clear the food in the mouth, and they saw the

resident declining and therefore the resident was

kept on a diet. In addition, the ST stated,

"trays and meals are not served until staff and the

nurse are present in the dining room."


#1 stated Resident #3 "is to be supervised at all

times because (he/she) is an A

nurse is supposed to be in the dining room if

meals and residents are present." The RN

further stated, "it should be on the resident's CP

and Kardex if the resident was on 1:1


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supervision."


#2 indicated that when residents are in the dining

room an RN always has to be in the dining room

to monitor the resident's diet and for

The RN further stated that would

be on the CNA's Kardex, PO's sheet and the CP.

During an interview on 7/2/19 at 3:30 p.m., the ST

stated "my last note and orders on , were

for recommendations of

with . I would not have

stopped the because, he/she was

an . If I would have known about

the order being changed I would have

recommended the to be continued."

During an interview with Resident #3's Physician,

on 7/2/19 at 4:05 p.m., the Physician stated, "I

think the D/C'd 1:1 supervision was a

transcription error." In addition, the Physician

explained "I do not think that

would have stopped a piece of food going down

the ST often writes

because of safety issues." The physician further

stated, "there should be a licensed nurse in the

dining room in case of an emergency."

During an interview on 7/2/19 at 5:35 p.m., RN #3

identified as the nurse who D/C'd the order,

stated that there was no doctor in the facility that

would discontinue a for a resident

with . In addition, RN #3

stated Resident #3 has always been on

with meals, if Resident #3 was not

supervised the Resident could . The RN

further stated, "I do not recall taking the order to

D/C ."


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Review of the facility's "New Jersey Universal

Transfer Form" undated, from the facility to the

hospital ER showed under "Reason for Transfer:"

on

,

. Under

"Mental Status:"

Review of the hospital "Emergency Record"

Physician's note dated at 6:10 p.m.,

included but was not limited to the following:

Under " Resident #3 was

. Under "Doctor Notes (DN)"

revealed the facility was contacted "to attain

further clarification of event and staff at

the facility stated [patient was eating food via (by)

his/her mouth unsupervised], and when they

checked on (the Resident), found him/her

, and

..." The DN also indicated according to

the Emergency Medical Service (EMS), the

Resident was found to be

) and in

severe by facility staff ." In

addition, the DN indicated that the EMS reported

that the patient had been eating by mouth

unsupervised, (and) may have on

food.... The DN also revealed Resident #3's

"Vital signs notable for

) and arrival. Patient

was in

...." The DN also

indicated the Resident required

admission for further evaluation and

management of the Resident's .

Review of the facility's policy titled


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Management" dated 2015, revealed the following:

Under "Description:" included is

impairment in any or all places of swallowing

resulting in the reduced ability to obtain adequate

nutrition by mouth and/ or reduced safety during

oral feeding...." Under "Purpose:" included "1. To

improve the patient's ability to safely consume the

least restrictive diet, (such as pureed, soft, or

regular) with the least amount or supervision...."

Review of the facility's policy titled "Meal Service"

dated 2/2019, Under Purpose: "To promote dining

with dignity and enjoyment of meals." Under

Procedure-Congregate Dining Location #6: "If

patient requires assistance with eating, do not

serve tray until able to stay and provide

assistance.... Provide supervision, limited

assistance, extensive assistance, or total

assistance as required level of self -performance

in eating...."








N.J.A.C: 8:39-11.2 (b)

N.J.A.C: 8:39-27.1(a)

N.J.A.C: 8:39-29. 2 (d)


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