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Based on observation, interview, and record review, the facility failed to ensure Schedule II medications were readily available for treatment in emergency cases. This deficient practice had the potential to affect all emergency room patients who were to receive provider ordered Schedule II medications. Findings include:

During an observation and interview on 4/26/22 at 11:30 a.m., there were no Schedule II medications readily available in the emergency department. During an interview, staff member F stated the facility did not keep Schedule II medications in the emergency department. If a provider ordered a Schedule II medication, the nurse would walk to the nurses' station at the other end of the hospital and locate the medication cart. Staff member F stated it could be difficult and time consuming to run back and forth from the emergency department to the nurses' station during an emergency.

During an interview on 4/28/22 at 9:00 a.m., staff member B stated all Schedule II medications used in the emergency department were kept in the medication cart which was located at the nurses' station on the other end of the hospital from the emergency room. She stated the nurse who was responsible for passing the regularly ordered medications to the extended care patients may have the medication cart with them in one of the two hallways off the nurses' station. The nurse providing care for patients in the emergency department would need to locate the medication cart to obtain any Schedule II medications.

A review of the facility's established list of medications kept readily available in the emergency room, did not include Schedule II medications.

Based on observation, interview, and record review, the facility failed to establish and implement policy and procedures for ensuring required equipment and supplies were readily available for use during an emergency on the crash cart. This had the potential to affect all patients who received care in the emergency department.

A request was submitted to the facility on 4/27/22, and 4/28/22, to provide a copy of the facility's policy and procedure for ensuring all necessary emergency medical supplies were available and inventory monitored and maintained. There was no policy provided by the end of the survey.

During an observation and interview on 4/26/22 at 11:30 a.m., crash cart #1 had a locked tag ID# 406793. A review of the facility's ER Checklist, for crash cart #1, showed the cart was last checked on 4/23/22, and a locked tag showed ID# 406747. The two tag ID #s did not match. During an interview, staff member F stated it was the responsibility of the night nurse to check and ensure the emergency supply inventory was maintained. She stated they were expected to check that daily and record the inventory review on the ER Checklist. Staff member F stated there had been a "code" in the emergency department on 4/24/22, and crash cart #1 had not been checked to ensure the necessary equipment was still available after the "code" occurred.

During a review of the facility's document titled, ER Checklist - Night Shift, on 4/26/22 at 11:30 a.m., for April 2022, showed Crash Cart #1 had locked tag ID# 406747 in place on the cart from 4/20/22 through 4/23/22. The cart had not been checked by facility staff from 4/24/22 through 4/26/22. Further review of the document showed there were no checks completed for emergency room supplies from 4/5/22 through 4/20/22.

During an interview on 4/27/22 at 8:00 a.m., staff member J stated it was the expectation that the emergency room supplies be readily available in the emergency department in the event of an emergency. She stated a crash cart should be reviewed for necessary emergency equipment after each time the cart was accessed to ensure supplies were readily available, and daily when not in use.

Based on observation, interview, and record review, the facility failed to establish, implement, and follow a policy and procedure for ensuring all essential mechanical, electrical, and patient-care equipment were identified and included on an inventory list which included a record of maintenance activities; failed to ensure all equipment was inspected and tested for performance and safety before initial use; and failed to ensure all essential medical equipment was maintained through a facility established maintenance strategy. The accumulative effect of this deficiency had the potential to affect all patients provided care services by the facility. Findings include:

A request was submitted to the facility on 4/27/22, and 4/28/22, to provide a copy of the facility's policy and procedure for ensuring all essential mechanical, electrical, and patient-care equipment was established in a maintenance program. There was no policy and procedure provided by the end of the survey.

During an observation on 4/26/22 at 10:30 a.m., the following emergency room based medical equipment was identified to not have a facility established maintenance sticker:

- GE brand EKG.
- Physio-Control Lucas 2 Chest Compression System.
- GE Corescape Patient Monitor.

During an interview on 4/26/22 at 10:30 a.m., staff member C stated they had been using the "new" GE brand EKG for approximately one month. She stated they had received the EKG from another facility.

During an interview on 4/26/22 at 11:30 a.m., staff member F stated she was not sure if the Lucas 2 Chest Compression System or the GE Corescape Monitor were on the facility's medical supply list or maintenance schedule.

A review of the facility's Active Equipment List, dated 3/8/22, did not include the GE Brand EKG, the Lucas 2 Chest Compression System, and the GE Corescape Patient Monitor.

During an interview on 4/28/22 at 8:30 a.m., staff member E stated the GE brand EKG, the Lucas 2 Chest Compression System, and the GE Corescape Patient Monitor were not included in their facility's Active Equipment List, and have not had an initial inspection prior to use and were not on the facility's established maintenance program. Staff member E stated they utilized a contract service to ensure the safety and performance inspections of the facility's medical equipment.

During an interview on 4/28/22 at 11:30 a.m., NF2 stated they provided, through contract, biomedical equipment maintenance for the facility. He stated if the identified equipment was not on the provided Active Equipment list, their company would not have provided maintenance for the equipment. He stated in order for their company to maintain the facility's equipment, the facility needed to inform them of any new equipment prior to it being used. This was to ensure they could add the equipment to the facility's Active Equipment List in order to provide the initial inspection, and periodic maintenance review of the identified equipment.

Based on interview and record review, the facility failed to ensure the facility's Group of Professionals (Medical Staff) presented the recommended policy and procedure changes for final decision to the Governing Board. This deficient practice had the potential to affect all patients and staff utilizing the policy. Findings include:

A review of the facility's policy and procedure titled, Pharmacy Policy and Procedures, showed the document to be in "draft" form. With a revision date of 8/27/21, and a reviewed date by the Group of Professionals, of 9/7/21.

During an interview on 4/28/22 at 10:18 a.m., staff member B stated the Medical Staff Committee completed their review and approval of the changes to the Pharmacy Policy and Procedures on 9/7/21. She stated the document had not been presented to the Governing Board for final approval. She stated this should have occurred by the next Governing Board meeting after the approval by the Medical Staff.

Based on observation, interview, and record review, the facility failed to develop and implement written policies and procedures for the safe administration and monitoring of patients receiving high-alert medications, including the safe administration of high-alert weight-based medications ¹. This deficient practice had the potential to affect all patients receiving high-alert medications. Findings include:

A request was submitted to the facility on 4/27/22, and 4/28/22, to provide a copy of the facility's policy and procedure for the safe administration and monitoring of high-alert medications to include the safe administration of weight-based dosed high-alert medications. A policy and procedure was not provided by the end of the survey.

During an observation and interview on 4/26/22 at 11:30 a.m., there was a standing scale and an infant scale in the emergency department. During an interview, staff member F stated if a patient was not able to stand on the scale, they would look up a weight in the patient's electronic chart. If they did not have a current weight recorded for the patient, or if the patient did not have a weight recorded in their medical record, they would not be able to obtain an accurate weight for a patient unable to stand on the scale.

During an interview on 4/28/22 at 10:00 a.m., staff member B stated the facility did not have a policy and procedure for the safe administration and monitoring of high-alert medications which included the safe administration of weight-based dosing of high-alert medications.

¹ "Home." Institute For Safe Medication Practices, https://www.ismp.org/.

Due to the manner and degree of the deficient practice, the facility failed to meet the Condition of Participation for Special Requirements for CAH Providers Long-Term Care.

Based on observation, interview, and record review, the facility failed to:

- Ensure staff with the appropriate competencies and/or a Registered Dietitian completed nutritional assessments on patients routinely and/or during a significant change in condition which, would require an updated nutritional assessment or change in diet orders;

- Ensure staff with the appropriate competencies prepared and provided therapeutic diets as ordered;

- Obtain a clarification order for when to provide "as needed (PRN) thickened liquids"; and, ensure the correct ordered liquid consistency was prepared and provided;

- Ensure staff were educated regarding what constitutes each textured diet and how to accurately prepare therapeutic liquid diet orders.

The accumulation of these deficient practices contributed to the following adverse outcomes. Findings include:

IMMEDIATE JEOPARDY

On 4/27/22 at 1:40 p.m., the facility Administrator, Chief Medical Officer, and Facility Governing Body Board Members, were notified that an Immediate Jeopardy existed in the area of §485.645 Condition of Participation: Special Requirements for CAH Providers of Long-Term Care Services, which was related to C1626.

PLAN TO REMOVE IMMEDIACY:

An acceptable plan to remove the Immediate Jeopardy was received on 4/27/22 at 6:45 p.m.

For §485.645: COP Swing Bed for (C1626) Nutrition:

- 1. All 4 patients will have a nutrition assessment done by the on call Provider, by Wednesday, April 27, 2022 at 4:30 pm.
a. Providers will write dietary orders for the patient based on the nutritional assessment
b. All PRN therapeutic diet orders were discontinued and permanent diet orders placed.

- 2. Nursing staff will monitor and assess tolerance of meals on a daily basis using a standardized tracking form. (Attached)
a. Any changes observed about the patient by dietary, or CNAs will be reported to the Charge Nurse, the Charge Nurse will report the changes to the Provider. If the Charge Nurse observes any changes, the changes will be reported to the Provider.
b. Identify any other patients that may need nutrition assessments based on observed changes or known medical events.

- 3. Immediate nutrition-education on therapeutic diets including solids and liquid will be given to dietary and nursing staff.
a. Dietary and nursing management will demonstrate and sign off on proficiency training provided by Nursing DON and Chief Medical Director.
b. Dietary and nursing management will educate their staff on therapeutic diets.
c. Each recipe has therapeutic diet instructions and will be followed to remain in compliance with that particular therapeutic diet.
d. Tray cards for therapeutic diets will be signed off by the cook and nurse to insure proper preparation.
e. Pre thickened liquids will be purchased and used in therapeutic diets.
f. Prior to shift change, dietary and nursing services will be educated on therapeutic solid and liquid preparation

- 4. Nursing will follow up on intake for 7 days post therapeutic diet change.
a. To monitor for change in food and fluid consumption after the nutrition assessment and training for meal and fluid consistency, food and fluid average will be calculated for a total of seven (7) days prior to this plan of correction. We will then calculate Food and Fluid consumption for the next 7 days to see if there is a change.

Dahl Memorial plans to have these corrections and educations done by 5:00 pm on April 28, 2022 to assert the likelihood for serious harm to any patients no longer exists.

REMOVAL OF IMMEDIACY

The removal of the immediacy was verified onsite by the State Survey Agency on 4/28/22 at 11:00 a.m. Once the immediacy was removed, the deficiency remained at a Condition Level.

Based on observation, interview, and record review, the facility failed to:

- ensure staff with the appropriate competencies and/or a Registered Dietitian completed nutritional assessments on patients routinely and/or during a significant change in condition, which would require an updated nutritional assessment or a change in diet orders for 4 (#s 1, 2, 3, and 4) patients;

- ensure staff with the appropriate competencies prepared and provided therapeutic diets as ordered for 4 (#s 1, 2, 3, and 4) patients;

- obtained a clarification order for when to provide "as needed (PRN) thickened liquids" for 1 patient (#4); and ensure the correct ordered liquid consistency was prepared and provided for 3 (#s 1, 3, and 4) patients;

- ensure staff were educated regarding what constitutes each textured diet and how to accurately prepare therapeutic liquid diet orders, which had the potential to affect all patients provided nutritional services by the facility.

The accumulation of these deficient practices contributed to the following adverse outcomes: actual harm related to pneumonia and a choking event which required emergent intervention for airway suction and oxygen desaturation for a patient with altered cognitive status for 1 (#1) patient; and the potential for more than likely harm related to aspiration and choking for 3 vulnerable patients (#s 2, 3, and 4) of 20 sampled patients.

IMMEDIATE JEOPARDY

On 4/27/22 at 1:40 p.m., the facility Administrator, Chief Medical Officer, and Facility Governing Body Board Members, were notified that an Immediate Jeopardy existed in the area of §485.645 Condition of Participation: Special Requirements for CAH Providers of Long-Term Care Services, which was related to C1626.

REMOVAL OF IMMEDIACY

An acceptable plan to remove the Immediate Jeopardy was received on 4/27/22 at 6:45 p.m.

The removal of the immediacy was verified onsite by the State Survey Agency on 4/28/22 at 11:00 a.m. Once the immediacy was removed, the deficiency remained at a Condition Level.

Findings include:

1. Competent Staff Preparing and Providing Therapeutic Diets:

Review of the facility's policy titled, Dietary Department, with an effective date of 7/1/21, showed:

- ..."1. The Dietary Manager works with the Registered Dietician (R.D.) to develop dietary services and organization meal plans which are consistent with best-practices and current federal and state regulations.

- 2. The Dietary Manager works with the R.D. to develop individualized meal plans for patients and residents for whom a special diet has been ordered...

- 5. The Dietary Manager works to ensure all staff are kept abreast of new developments in the fields of nutrition and dietary department safety, sanitation and efficiency..."

Review of the facility's policy titled, Therapeutic/Special Diets, with an effective date of 7/1/21, showed:

- ..."1. b. Therapeutic diet substitutions and changes may be ordered by the attending provider and/or R.D...

- 3. The RD ensures specific foods and meals are appropriate for the patient/resident's special diet order...

- 7. The RD consults with the attending provider as necessary and appropriate to ensure the therapeutic diet supports achieving the patient/resident's nutritional health goals.

- 8. The RD ensures both nursing and dietary staff are aware of therapeutic diet order changes.[sic]"

During an interview on 4/26/22 at 10:15 a.m., staff member N stated she had been in the position of Dietary Manager for the past year and a half. Staff member N stated her training consisted of self-directed education and a four-hour ServSafe class online. She stated she did not have a copy of her completion of the ServSafe training. Staff member N stated there currently was no Registered Dietitian working at the facility.

During an observation and interview at 4/26/22 at 10:23 a.m., broccoli was being boiled in a large pot on the stove top in the kitchen. Located directly above the stove top was a metal pan, which contained frozen bacon wrapped in a sealed plastic bag. Staff member AA stated he needed eight slices of bacon to prepare the lunch menu. He said he had placed the bacon on the shelf to thaw out. Staff member AA stated he did not know that bacon should not be thawed at room temperature.

During an observation and interview on 4/26/22 at 10:24 a.m., staff member AA was wearing a personal baseball cap and was not wearing a hairnet. He said he was unaware he needed to wear a hairnet in the kitchen. He said he was a full-time cook and had worked at the facility for approximately three months. Staff member AA stated he had not completed any formal training to work in the kitchen. He said staff member N was teaching him what he needed to know.

During an observation and interview on 4/26/22 at 10:40 a.m., staff member N tested the bleach solution used for the kitchen surface cleaning. The bleach solution was located in the sink adjacent to the food prep area. According to the test strip dipped into the water by staff member N, no bleach was detected in the solution. Staff member AA stated he had last tested the bleach solution when he came to work before 7:00 a.m., that morning. Staff member N instructed staff member AA to prepare a new bucket of bleach solution and re-test the solution.

During an interview on 4/26/22 at 10:44 a.m., staff member N stated staff member NF1 had not been at the facility since approximately November of 2021. Staff member N stated new patients had been admitted since then, but had not been seen by a dietitian. She stated she performed the nutritional assessments for the patients and the provider writes the dietary orders.

During an interview on 4/26/22 at 2:22 p.m., staff member A stated the Registered Dietitian, who had been working at the facility, would not return his phone calls and had resigned. Staff member A stated the last time NF1 was at the facility was approximately October of 2021. Staff member A stated he did not have documented records of attempts at locating a Registered Dietitian and did not have access to a speech therapist to perform evaluations of patients with specialized dietary needs.

The facility provided a list of all full and part-time employees that worked in the kitchen, and all their training certifications. The list included the dietary manager, five cooks, and ten dietary aides. Staff member N had completed a training on 7/21/10, titled, "Senior Nutrition Programs." Two cooks had completed safe food handler training and were current with those certifications. No other specialized training documentation was provided for the dietary manager, which had performed all the nutritional assessments for the patients since November of 2021. No training documentation was provided for any of the dietary aides or remaining cooks employed by the facility.

2. Patient #1

Review of patient #1's current diagnoses, dated 4/27/22, showed:

- "Unspecified dementia without behavioral disturbances,
- Hemiplegia and hemiparesis following cerebral infarction affecting right non-dominant side,
- Dysphagia following cerebral infarction,
- Personal history of transient ischemic attack..."

Review of patient #1's Brief Interview for Mental Status, dated 3/9/21 at 11:06 a.m., showed a score of 11, which indicated moderate impairment of cognitive ability.

Review of patient #1's Nutritional Assessment, completed by staff member N, dated 3/3/21 at 2:21 p.m., showed:

- ..."Diet Type - No added salt, Diabetic,
- Diet Texture - Regular, and
- Fluid Texture - Nectar..."

A review of patient #1's Provider Orders, after the completion of the Nutritional Assessment dated 3/3/21 which was completed by a staff member without the qualified competencies for ordering diet textures, showed there were no diet orders that reflected the ordered diet of regular texture and Nectar thick fluids. There were no further diet orders in patient #1's medical record until 6/7/21.

Review of patient #1's Nursing Progress Note, dated 5/22/21 at 3:34 p.m., showed, "While sitting in recliner in his room, patient began choking on his afternoon snack. He is able to forcefully cough, so much his face turned red... Will have patient eat all of his meals in the dining room today, in order for nurse to closely monitor during meals."

Review of patient #1's Nursing Progress Note, dated 5/23/21 at 8:59 a.m., showed, "Patient to dining room for breakfast, he was coughing at the beginning of breakfast. Held his toast and raisins from the oatmeal... SaO2 83% w/4 L oxygen. Lung sounds difficult to assess, as patient makes a grunting noise when he exhales. Auscultate inspiratory wheezes in upper lobes; administered Albuterol SVN. After albuterol SVN, no wheezes heard, lung sounds diminished throughout, and barely audible in bilateral bases..."

Review of patient #1's Nursing Progress Note, dated 5/25/21 at 4:10 p.m., showed, "Resident has not had any episodes of aspiration or chocking [sic] or difficulty swallowing with meals since episode on Sunday. Per provider order to increase thickener in fluids and to thicken any semi-solid foods as needed to avoid aspiration..." No updated provider orders for a change in consistency of liquids or change of diet texture were documented at the time of this progress note.

Review of patient #1's Physician Orders List, dated 6/7/21, showed diet consistency ordered as, "Mechanical soft diet with honey thick liquids for all meals and snacks. Dx: Dysphagia." No new nutritional assessments were completed at the time of the diet texture and liquid consistency change.

Review of patient #1's Nurses Progress Note, dated 6/25/21 at 11:38 a.m., showed, "Patient with acute altered mental status. He is very lethargic..."

Review of patient #1's Nursing Progress Note, dated 6/26/21 at 4:41 p.m., showed, "Checked SaO2 before starting 1600 [4:00 p.m.] SVN - was 53%. Patient was not getting oxygen from the concentrator. ... Reconnected water bottle, oxygen concentrator is set at 5 L/min and he uses nasal cannula. Rechecked SaO2 after 15 minutes, the highest was 87% on 5 L/min."

Review of patient #1's Nursing Progress Note, dated 6/28/21 at 1:41 p.m., showed, "Order received for oral Levaquin 500 mg PO daily for 7 days for new diagnosis of multilobular pneumonia..."

Review of patient #1's Admission Note, dated 7/24/21 at 3:00 p.m., showed the patient was admitted to the acute side of the CAH with diagnoses which included: pneumonia, hypoxia, and acute respiratory distress. Patient #1 was discharged from the acute side of the CAH, back to the LTC side of the CAH on 7/27/21. A review of patient #1's medical record showed no new nutritional assessments were completed at that time of significant change in condition.

Review of patient #1's Nursing Progress Note, dated 11/20/21 at 10:48 p.m., showed, "At supper earlier this evening around 1800 [6:00 p.m.], resident aspirated on his soup. Resident started coughing and then puked up his supper. Resident was taken back to his room, lung sounds were normal and oxygen saturation was above 90% on his usual 4 L of oxygen. Resident has no complaints of discomfort or increased shortness of breath." A review of patient #1's medical record after the aspiration occurrence on 11/20/21, did not show that a new nutritional assessment was completed after patient #1 aspirated on soup, no additional precautions to prevent aspiration were implemented, and no documentation of notification to the provider of aspiration episode or referrals to have patient #1 evaluated for his swallowing ability.

Review of patient #1's Admission Note dated 2/22/22 at 3:11 p.m., showed, "Patient has become progressively more fatigued as the day has gone on. He is slightly more short of breath and coughing more than normal. He has a history of aspiration pneumonia..."

Review of patient #1's Chest X-Ray dated 2/22/22 at 5:10 p.m., showed, "Impression: Left lower lung infiltrate. Right perihilar infiltrate. Cardiomegaly." A perihilar infiltrate was a condition in which any foreign substance gets stuck in the perihilar region of the lungs.

Review of patient #1's Swing Bed Discharge Summary, dated 2/28/22 at 11:01 a.m., showed a diagnosis of right middle lobe pneumonia. Patient #1 was re-admitted to the LTC side of the hospital. No new nutritional assessments were completed after patient #1's readmission to the LTC side of the hospital, and/or after his change in condition and/or hospitalization.

Review of patient #1's Nursing Progress Note, dated 4/11/22 at 6:47 p.m., showed, "CNA notified nurse that [patient #1] was choking on Tortellini noodles at supper. The CNA pulled one noodles [sic] out of his mouth. He was able to clear his own airway... Lung Sounds: Right lobe sounds are very diminished; left lobe breath sounds diminished - No adventitious sounds in either lung. SaO2 85% on 5 L/min via nasal cannula. He denies shortness of breath. Advised him to notify nursing if his energy decreases, cough increases, sputum increases, he doesn't feel well over the next few days."

Review of patient #1's Nursing Progress Note, dated 4/22/22 at 5:33 a.m., showed, "...Resident finished PRN Albuterol treatment per order by provider...for food aspiration that was initiated on day shift. Lung sounds are full of crackles and rhonchi throughout entirety of lung fields upon auscultation. Resident's voice is very wet and has noticble [sic] excess of secretions. ...Resident was weak, wet productive cough. ...Residents oxygen saturation remains in low 80's (81-83%) on 6 L of O2 via nasal cannula. RN applied continuous SPO2 monitoring to assess saturation rate. RN switched resident to face mask at 10 L/min and was unable to achieve saturations >90%. RN notified on-call provider [staff member L] of residents desaturations and difficulty achieving adequate perfusion. Provider requested another round of PRN Budesonide aerosol treatment. RN then placed resident on non-rebreather mask @ 15 L/min via wall oxygen to achieve saturation of 93%, and applied PRN treatment as directed. Patient was able to maintain saturations > 90% following treatment and throughout night shift."

Review of patient #1's Chest X-Ray, dated 4/22/22 at 1:05 p.m., showed, ..."There is right upper lung atelectasis. There is left mid and lower lung atelectasis..." Atelectasis is a condition in which the lung is "collapsed" or there is a closure of the lung, resulting in reduced or absent gas exchange.

A review of patient #1's medical record showed the facility failed to complete additional nursing and/or Registered Dietitian assessments or SLP evaluation. There were no further provider nutritional assessments or orders which addressed patient #1's aspiration events on 4/11/22 and 4/22/22.

During an observation on 4/26/22 at 12:16 p.m., patient #1 was eating lunch independently with staff seated across the table from him. Patient #1 was eating ground chicken from a bowl, with a dry, crumbly consistency, and had a small bowl of green, pureed vegetables also sitting on table. Patient #1 was quickly spooning the chicken into his mouth, without pausing in between spoonful's. Patient #1 was forcibly coughing, with food dropping out of his mouth onto his chin and clothing protector. Patient #1's face was reddened, and he continued to cough. Patient #1 reached for his enclosed cup with a straw, which contained thickened water, and took a drink. Patient #1 stopped coughing after the sip of water and continued to eat. Staff in the dining room area did not approach patient #1 while he was coughing or provide him with assistance during or after the coughing episode.

During an interview on 4/26/22 at 1:50 p.m., staff member B stated the facility currently did not have a Registered Dietitian. She said the nursing staff performed the dietary evaluation for patients upon admission, and when there was a significant change of condition. Staff member B stated the completion of the dietary evaluations were a problem that needed improvement and they (administration) had been working on it for the last 6-12 months. Staff member B stated there was an incident "last week [week of 4/18/22]" when patient #1 had choked on a piece of broccoli. She said he was able to dislodge the piece of broccoli from his throat by himself. Staff member B stated they had not completed an incident report regarding the choking incident. She stated the administration had a meeting to discuss a disagreement which occurred between the dietary department and the nursing department, on whose responsibility it was for ensuring "diets and oversight."

During an interview on 4/26/22 at 2:30 p.m., staff member A stated they had a meeting to discuss the choking incident which occurred, "last week [week of 4/18/22]", for patient #1. He stated they did not have any notes from the meeting which they had discussed patient #1's choking incident and diet orders. Staff member A stated it was the expectation for staff to follow the ordered diet in order to prevent further choking episodes for patient #1.

During an interview on 4/26/22 at 2:50 p.m., staff member F stated patient #1 had coughed up the stem from a piece of broccoli, on 4/21/22. She stated the night nurse had to increase the patient's oxygen overnight, and administer extra nebulizer treatments; patient #1 had to have an x-ray completed on 4/22/22. Staff member F stated patient #1 had not received a new nutritional assessment, his assessments were not up-to-date.

During an interview on 4/26/22 at 3:05 p.m., staff member U stated patient #1 had a history of dysphagia and pneumonia. Staff member U stated patient #1 had choked on and then coughed up a stem from a piece of broccoli at dinner on 4/21/22. After the choking episode, patient #1 required an increase in his oxygen delivery up to 15 L/min, with a non-rebreather mask, due to his oxygen saturation decreasing into the 80's. Patient #1 also received additional medication delivered via a nebulizer treatment. Staff member U stated patient #1's lung sounds were full of crackles and rhonchi in all lung fields. Staff member F stated it was not abnormal for patient #1 to cough as he was an aspiration risk because he eats too fast and the anatomy of his body. Staff member U stated there was a lack of knowledge in the dietary department on how to identify differences in diet textures. He said nursing has had to repeatedly assist the dietary staff on therapeutic diet consistencies. Stating for example, adding gravy for moisture, to meats. He said nursing has had to provide direct observation of what food and diet textures were being served by the kitchen. Staff member U stated the nursing staff has had to provide daily education and oversight such as, "You know this patient shouldn't have this." Staff member U stated dietary was asking nursing more frequently if certain foods were acceptable for certain diets.

During an interview on 4/26/22 at 3:11 p.m., staff member Q stated after patient #1 choked on 4/21/22, he was moved to the emergency department where he had to have his airway suctioned.

During an interview on 4/26/22 at 3:34 p.m., staff member B stated after patient #1 had choked on broccoli, he was wheeled to the emergency room to have his airway suctioned.

During an observation and interview on 4/26/22 at 3:37 p.m., staff member S was passing out fluids for the residents' afternoon fluid pass. She provided patient #1 with a clear pitcher of yellow fluid, which was regular consistency. Staff member R then stopped staff member S, explaining patient #1 was to have his fluids thickened. Staff member R then added two pre-packaged packets of ThickenUP to the patient's 200 fluid ml pitcher. She stated she believed he was to receive "honey-thick" fluid consistency. She stated she was not sure what that should look like and had never been provided training or education on how much thickener to use when thickening the patient's liquids. She stated she might ask the nurse if they knew how to thicken the liquids. During the observation, patient #1 had additional containers on his over-the-bed table which contained non-thickened water and juice.

During an interview on 4/26/22 at 4:12 p.m., staff member R stated she had to thicken patient #1's drinks at lunch today. She stated the "old" bucket of liquid thickener had directions on the container for how much to use for each type of liquid consistency. She stated due to an infection control concern with the scoops in the larger containers of thickener, the facility started using the pre-filled packets of ThickenUP. She stated she had not received training from the facility on how to thicken fluids to the correct consistency and would try to follow the directions on the back of the packet. The directions on the back of the pre-filled packets were not as comprehensive as the larger containers for consistency measurements.

During an interview on 4/26/22 at 4:16 p.m., staff member B stated after patient #1 had choked on the piece of broccoli, his lips had turned blue. Staff member B stated a dietitian, with the help of the dietary manager, should be doing the dietary assessments on patients.

During an interview on 4/26/22 at 4:17 p.m., staff member N stated she had no training on how to do a nutritional assessment. Staff member N stated patient #1 received pureed green beans today instead of broccoli, even though his diet did not call for pureed foods. She stated she was afraid to serve patient #1 broccoli due to his choking incident.

During an interview on 4/26/22 at 4:21 p.m., staff member A stated the facility did not have a dietitian and after the choking event with patient #1, administration discovered where they needed to begin with education for the staff. He stated they had not yet provided such education, and he was also aware they were behind on their nutritional assessments, and knew they needed a Registered Dietitian.

3. Patient #2

Review of patient #2's current diagnoses, dated 4/27/22, showed:

- "Unspecified focal traumatic brain injury, and
- Torticollis. ..."

Review of patient #2's Dietary Order, dated 2/3/21, showed, "Mechanical Soft Diet" with no indication for the mechanical soft diet. A review of patient #2's medical record did not show the patient had a nutritional assessment prior to 2/3/21.

Review of patient #2's Nutritional Assessment dated 7/23/21, was completed by staff member N, showed:

- Diet Texture - "Mechanical soft"
- Fluid Texture - "Nectar..."

There were no provider orders for the fluid texture of "Nectar Thickened."

Review of patient #2's Dietitian Progress Note, dated 7/23/21 at 12:05 p.m., showed, "[Patient #2] continues with a regular diet with mechanical soft textures and regular consistencies..." The progress note did not mention the fluid texture for "Nectar" thick.

Review of patient #2's dietary orders, dated 4/22/22, showed, "Nectar thickened liquids." There was no indication for diet order, and no nutritional assessments by a staff member with appropriate competencies and certifications, and/or a SLP evaluation prior to this updated diet order.

During an observation on 4/26/22 at 12:14 p.m., patient #2 was sitting at the table, in a wheelchair, waiting to be assisted with the lunch meal. In front of patient #2 were two covered cups with straws. Patient #2 had extensive contractures in both hands and his head was severely twisted toward his right shoulder, with his right ear almost touching his shoulder. Patient #2 was unable to feed himself and required staff member R to provide total assistance. Staff member R assisted patient #2 with his meal.

During an interview and record review on 4/26/22 at 2:00 p.m., the facility's spreadsheet/document titled, Water Pass Cheat, undated, which was attached to the beverage cart, showed for patient #2, under the heading, "Thicken," "Yes." No description was on the document regarding the consistency of the liquids to be served. No instructions were included on the document for how much thickener to add to the liquids for a specific liquid texture. During an interview, staff member S stated they recently placed that spreadsheet on the fluid cart to show which patients were to receive thickened liquids. She stated she had the nurses thicken any necessary fluids.

During an interview on 4/26/22 at 2:56 p.m., staff member F stated charts were audited for diet orders after patient #1 choked on a piece of broccoli and new diet orders were written for patient #2.

During an interview on 4/26/22 at 4:12 p.m., staff member R stated there needs to be training on the thickening of patient's liquids. She stated there were inconsistencies on how and when to thicken liquids.

4. Patient #3

Review of patient #3's Nutritional Assessment, dated 6/17/21 and completed by staff member N, showed:

- Diet Texture - "Regular"
- Fluid Texture - "Regular"

Review of patient #3's Dietary Orders, dated 2/15/22, showed, "Soft foods diet due to thyroid nodule and throat pain." No additional nutritional assessment was completed for the dietary order changes.

Review of patient #3's Dietary Orders, dated 4/22/22, showed, "Nectar thickened liquids." No nutritional assessment was completed and the order lacked an indication for the fluid texture change.

During an observation and interview on 4/26/22 at 1:40 p.m., patient #3 was sitting in a recliner in her room. She had a large clear pitcher filled with a yellow liquid, which was regular consistency, next to her on her table. There was also a Shasta can with a straw, which was not thickened and a small glass of water which was not thickened. Patient #3 stated she coughed often when drinking and eating because of her enlarged thyroid. She stated she believed her fluids were supposed to be thickened to help with her swallowing, but the staff did not always provide her with thickened fluids.

Review of the facility's spreadsheet/document titled, Water Pass Cheat, undated, which was attached to the beverage cart, showed for patient #3, under the heading, "Thicken," "Yes." No description was on the document regarding the consistency of the liquids to be served. No instructions were included on the document for how much thickener to add to the liquids for specific liquid textures.

5. Patient #4

Review of patient #4's current diagnoses, dated 4/27/22, showed, dysphagia and dementia.

Review of patient #4's Nutritional Assessments/Evaluations, completed from 2/4/21 to 3/17/22, by staff member N, showed the following inconsistencies:

- 2/4/21: Diet/Fluid Texture Regular,
- 5/11/21: Diet/Fluid Texture Regular,
- 12/3/21: Food Texture Modification "Yes" Choking/Swallowing problems "Yes"
- 12/29/21: Food Texture Modification "No" Choking/Swallowing problems "No"
- 2/10/22: Food Texture Modification "Yes" Choking/Swallowing problems "Yes"; and
- 3/17/22: Food Texture Modification "Yes" Choking/Swallowing problems "Yes"

A review of patient #4's medical record did not show diet or fluid orders were written, or assessments completed by a staff member with appropriate competencies and/or certifications.

Review of patient #4's Dietary Orders, dated 4/22/22, showed, "Soft food diet and nectar thickened liquids PRN." There were no clarification orders for the PRN, no additional assessments completed by a qualified staff member, and there were no diet orders completed for a change in swallowing ability, which would require new assessment/orders.

During an observation on 4/26/22 at 12:08 p.m., patient #4 was sitting at a table waiting for lunch to be served. Patient #4 had a large glass of unthickened water that had already been placed at her setting prior to her arrival. After patient #4's food had been placed in front of her, staff member N placed a small glass of unthickened apple juice alongside her plate. Thickener packets were sitting in the middle of the table where patient #4 was seated. Staff member R was seated next to patient #2, assisting him with his lunch meal, at the table next to patient #4's table. Staff member R got up from her chair, walked over to patient #4's table, grabbed the liquid thickener packets and stated to staff member N, "Those (liquids) need to be thickened." Staff member R opened and poured one liquid thickener packet into patient #4's water and apple juice, then proceeded to stir the liquids.

During an interview on 4/27/22 at 8:29 a.m., staff member J stated nutritional assessments were completed by nursing staff, the dietary manager, and the registered dietitian. She stated assessments were completed when there was a change of status, such as swallowing issues. Staff member J stated NF1 was currently completing the patients' dietary assessments. Staff member J was unaware NF1 no longer worked at the facility. She stated she was unaware that a meeting took place, regarding dietary/nutrition concerns after patient #1 choked on a piece of broccoli on 4/21/22. Staff member J stated she should have been involved in the process, as that was her role in leadership.