AIKEN, SC – PRUITTHEALTH-AIKEN

The facility failed to provide adequate supervision to maintain a safe environment for the resident and on [DATE], the resident was on a physician ordered pureed diet when the resident choked on a peanut butter sandwich. The resident was sent to hospital later that day, returned to the facility on [DATE] on Hospice and expired at the facility on [DATE].

The facility’s failure to implement policy and ensure care plan interventions were revised and implemented resulted in a failure to provide adequate supervision to Resident #16 to ensure safety. The resident had a physician ordered pureed diet and on [DATE] the resident was observed having difficulty breathing. When assessed by staff the resident was pale, with low oxygen saturation levels and a peanut butter sandwich was found in the resident’s mouth. Staff worked with the resident for approximately one (1) hour attempting to get the resident’s oxygen saturation level up. Staff sat with the resident for several hours. Later that evening the resident experienced respiratory distress and was sent to the emergency room . The resident returned to the facility on [DATE] on Hospice care for [MEDICAL CONDITION] related to pneumonia. The resident expired at the facility on [DATE]. The facility Administrator was notified of the Immediate Jeopardy on [DATE] at 1:30 PM.

A telephone interview was conducted with RN #1 on [DATE] at 10:00 AM The RN stated she received in report when coming on duty on [DATE] at 7:00 PM that Resident #16 had aspirated on a sandwich earlier in the day, the resident had choked, and oxygen saturations levels dropped significantly. The RN was told that staff had to work on the resident for a couple of hours to get oxygen saturation levels up. The RN said he/she questioned the nurse going off duty why the resident had not been sent out to the hospital to be evaluated, because the nurse would not be able to closely monitor the resident that evening because the RN was responsible for approximately 40 residents when coming on duty. RN #1 stated the resident was up walking the halls at 7:00 PM and when it was time to administer the resident’s scheduled breathing treatment at approximately 9:30 p.m., the resident could barely stand up and was very pale, the resident’s breathing was very loud, it sounded like a death rattle. The RN said she took the resident’s oxygen saturation levels and they were down in the 70’s with heart rate around 130, and the RN could actually hear the resident’s breathing from down the hallway. RN #1 contacted the Nurse Practitioner on call and resident was sent out to emergency room for an evaluation. The nurse concluded, I could not understand why the resident was not sent out earlier.