POTTSVILLE, PA – MANORCARE HEALTH SERVICES-POTTSVILLE

Based on a review of clinical records, the facility Diet Manual and select facility investigative reports and staff interview, it was determined the facility failed to ensure that food was served in a form to meet the individual needs of one of 19 residents sampled that resulted in actual harm to that resident (Resident 89) who expired as a result of the choking episode.

Review of a facility, Incident Report Timeline of Critical Events: dated [DATE], revealed that on that date at 5:55 PM Employee 4 (LPN) was in the hallway when Resident 53 (Resident 89’s roommate) came out into the hall and said help, help there is something wrong with her (Resident 89). Employee 3 (RN) was standing by the nurses desk. Employee 4 (LPN) and Employee 3 (RN) ran into Resident 89’s room. Resident 89 was struggling to breathe and pointing at her meal tray. Employee 3 (RN) knew Resident 89 was telling Employee 3 (RN) she was choking. Employees 4 (LPN) and Employee 3 (RN) sat the resident straight up in bed. Employee 4 (LPN) climbed into bed and started doing the [MEDICATION(S)] maneuver (first-aid technique for someone who is choking because food or another swallowed object is obstructing his or her airway. Using an upward abdominal thrust, the [MEDICATION(S)] maneuver compresses the lungs and forces air up into the windpipe {trachea} until the object causing the choking is ejected from the throat). Resident 89 was laid on her side for a finger sweep. No food was found. Resident 89 was sat back up and the [MEDICATION(S)] maneuver was resumed. Oxygen was initiated. Code Blue was initiated and 911 was called. The [MEDICATION(S)] maneuver continued.

At 6:10 PM EMS arrived and asked Employee 4 (LPN) if Resident 89 was in [CONDITION(S)]. Employee 4 (LPN) stated no she is breathing and responsive. Resident 89 then became unresponsive. EMS instructed Employee 4 (LPN) to start chest compressions until equipment prepared. EMS placed leads and could not find a rhythm (heartbeat). CPR (cardiopulmonary resuscitation- a medical procedure involving repeated compression of a patient’s chest, performed in an attempt to restore the blood circulation and breathing of a person who has suffered [CONDITION(S)]) was resumed. EMS turned Resident 89’s head for another finger sweep and a whole green grape was in her mouth. EMS intubated (placement of a flexible plastic tube into the trachea to maintain an open airway) the resident and another whole green grape came out. Rhythm checked and EMS shocked times one and rhythm resumed. Employee 4 (LPN) was manually ventilating Resident 89 with Ambu bag (a handheld device commonly used to provide positive pressure ventilation when not breathing or not breathing adequately) and as manually ventilating Resident 89 pureed food was coming up in the tube. Resident 89 was suctioned. Resident 89 was transferred to EMS litter (stretcher). Resident left the facility with a pulse while being manually ventilated.

A late entry general progress note dated [DATE], at 7:45 PM noted that a call was received from the emergency room informing the facility that Resident 89 was pronounced deceased following [CONDITION(S)] that did not respond to ACLS (advanced cardiovascular life support) efforts.

Interview with the Director of Nursing (DON) on [DATE], at approximately 10:00 AM confirmed Resident 89’s received food (fruit cocktail) that was not in a form to meet the resident’s needs for safe swallowing to prevent the resident from choking.