Edgewood Alexandria Senior Liv.

Finding: Substantiated, facility responsibility Nature of Investigation: The Minnesota Department of Health investigated an allegation of maltreatment, in accordance with the Minnesota Reporting of Maltreatment of Vulnerable Adults Act, Minn. Stat. 626.557, and to evaluate compliance with applicable licensing standards for the provider type. Initial Investigation Allegation(s): The facility neglected the resident when staff failed to provide adequate supervision during mealtime. The resident was found slumped over in her chair and appeared to be choking. Staff attempted the Heimlich maneuver, but the resident died shortly after emergency services arrived. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was substantiated. The facility was responsible for the maltreatment. Facility staff were aware of the resident’s recent choking incident and recent change in diet prior to admission. However, nursing staff failed to address the resident’s history of choking in the care plan and failed to implement specific interventions to minimize the resident’s risk of choking. The resident choked on a piece of meat and died approximately three months after admission to the facility. An equal opportunity employer. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted law enforcement and the resident’s primary care provider. The investigation included review of the police report, death record, and facility records, including the service plan, assessments, and progress notes. Also, the investigator observed meal service provided at the facility. The resident resided in an assisted living memory care unit. The resident’s diagnoses included Alzheimer’s disease, dementia, and adjustment disorder with mixed anxiety and depressed mood. The resident’s service plan included assistance with dressing, grooming, bathing, toileting, safety checks, and medication administration. The service plan did not include assistance or supervision for eating. The resident’s assessment indicated the resident had a good appetite and needed some help with meal set up. Staff were to assist with cutting up food as needed and were directed to notify the nurse of any concerns with food intake. The resident’s medical record included three sets of physician orders signed around the time of admission to the facility. The first order was initiated one month prior to admission, after the resident choked on a piece of meat and was evaluated in the emergency room. The order included a mechanical soft (pureed, ground, finely chopped, or blended) diet. The second order, titled General Admission Orders, indicated the resident had a mechanical soft diet. A note next to the order included the following, "Note- This community cannot accommodate diets for modified consistency. Compliance with dietary restrictions is at the discretion of the resident." The orders were signed by the provider three days prior to the resident’s admission to the facility. A third set of signed orders, sent from the previous assisted living facility, included "diet order change request: Resident sustained a choking episode on [date] due to non-cut up meat. Resident was then placed on a mechanical soft diet. Resident is moving to Edgewood on [date] and they are unable to accommodate a mechanical soft diet. Ok to change to regular texture with cut up assistance?" The provider signed off on the order "ok as above.” The resident's Department of Human Services Resident Service Plan, provided to the facility by the resident’s case worker, indicated staff were to cut up the resident's food. Page seven of the service plan indicated for staff to "monitor for swallowing concerns (recent Heimlich due to choking, orders for mechanical soft texture diet.)" An acknowledgement of the service plan was signed by the facility’s clinical nurse supervisor (CNS), confirming she reviewed the plan and agreed to provide the services and supports outlined in the document. An email sent to the memory care registered nurse (RN) from the resident's case manager about one month after the resident admitted to the facility, included the following, "...I noted a couple of things that were in the previous RS [resident service] plan and/or CP [care plan] at [previous assisted living facility] but am not seeing in her current CP or profile...I maybe missed them but at least wanted to address...eating: [previous assisted living facility] reported that she had an order for mechanical soft diet following her choking episode in March. Was this passed onto Edgewood? Wondering if a note under eating re: her history of needing Heimlich and ER for choking in March should be noted in her care plan? (hoping this info was passed onto Edgewood during the transition)". The RN failed to include the information outlined in the case manager’s email in the resident's care plan or assessments. The resident’s medical record did not address the resident's recent history of requiring the Heimlich maneuver after choking on a piece of meat and/or how the facility would minimize the resident’s risk of choking. Two assessments, completed one month prior to the resident’s death, did not include information on the resident’s recent choking episode or need to monitor the resident while eating. The resident's individual abuse prevention plan (IAPP) lacked any assessment of the past choking incident, the resident's history of eating quickly, or measures to be taken to reduce the resident’s risk of choking. The IAPP indicated the resident had adequate nutrition and had a good appetite. Staff were to assist as needed with cutting up food for the resident and notify the nurse if any concerns with intake were noted. A facility incident report indicated the resident was at the table in the dining room eating her dinner when staff noticed she was slumped over with her head down. A staff member started the Heimlich maneuver, called 911, and the on-call nurse. The on-call nurse advised staff to continue with the Heimlich maneuver, however it was unsuccessful, and the resident became unconscious. The resident was lowered to the floor and staff attempted a finger sweep to remove the food from the resident’s mouth. Some food was removed, but they were unable to clear the airway. Emergency medical services and police arrived and took over care of the resident. Police were provided the resident’s do not resuscitate (DNR) order and the resident was declared dead. The resident’s death record listed food bolus asphyxia (choking on food) as the cause of death. The death record indicated the resident choked on a piece of bratwurst/hotdog and died within minutes. During interviews with facility staff, including licensed nurses and unlicensed personnel, they stated the resident did not have special dietary needs and they were unaware of any previous choking episodes. Several staff members stated the resident would eat very fast, but they had not received direction on any specific interventions to reduce her risk of choking. During an interview, the resident’s case manager stated she had several verbal and email communications with facility staff, specifically the clinical nurse supervisor (CNS) and registered nurse (RN), regarding the resident's history of choking and the need to monitor for choking since she would no longer be receiving a modified diet. The case manager noticed the facility's care plan did not address the resident's recent choking episode or her risk for choking again, along with the need to monitor for choking while eating. The case manager reached out to the facility to address her concerns and received a reply that the facility would add the information to their care plan for the resident. The case manager stated she made sure the rate plan for the county reflected the need to monitor for choking, and the facility signed off on the rate plan, so she assumed they read it. The case manager stated facility staff should have been aware the resident was at high risk for choking and it should have been addressed in her care plan. During an interview, the CNS confirmed the resident's record lacked information on her past choking episode, and there were no interventions put in place to prevent choking after the resident’s diet changed from mechanical soft to regular. The CNS stated she didn't know if anyone had reviewed with the resident's power of attorney the risks related to eating a regular diet versus a mechanical soft one because "that was the doctor's choice; she [the doctor] decided that was correct and agreed to change the diet." The CNS said it would have been the responsibility of the previous facility to review these risks, despite the diet change being made at the request of Edgewood staff as a condition of admission.