MEMPHIS,TN – MIDTOWN CENTER FOR HEALTH AND REHABILITATION

Based on policy review, medical record review, observation, and interview, the facility failed to ensure safety and provide individualized resident care for 1 of 12 sampled residents (Resident #1) reviewed with modified diets and/or required assistance with meals. The facility failure resulted in Immediate Jeopardy when Resident #1 was fed a regular diet instead of the ordered pureed diet (a texture modified diet in which all foods have a soft, pudding like consistency) and the Agency Certified Nursing Assistant (CNA) left the resident unattended after feeding the resident. Resident #1 was found unresponsive, a portion of a hotdog was removed with forceps by Emergency Medical Services (EMS), and Resident #1 expired in the emergency room (ER) of a local hospital.

Immediate Jeopardy (IJ) is a situation in which the provider’s noncompliance with one or more requirements  of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident.

The Administrator and Interim Director of Nursing (DON) were notified of the Immediate Jeopardy on [DATE] at 6:50 PM, in the Chapel.

The facility was cited Immediate Jeopardy at F-600.

The facility was cited F-600 at a scope and severity of J, which is Substandard Quality of Care.

The IJ was effective from [DATE] through [DATE].

An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on [DATE] at 2:26 PM and was validated onsite by the surveyors on [DATE] through observation, review of audits and meeting minutes, and staff interviews.

Review of the facility’s investigation dated [DATE], revealed .On [DATE], during the dinner meal pass, [Named CNA #20, an Agency CNA] .grab [grabbed] a tray that had the letter F and the letter B on the tray card. The tray she picked [with a regular diet instead of ordered puree diet] had another resident [picture] with a hat on, causing it to look similar to Ms. [Named Resident #1] picture; both Resident [Resident #1 and Resident #2, which was the resident’s tray she selected to deliver to Resident #1] had hats on in their pictures [pictures of the residents are located on the bottom of the tray card] .[Named CNA #20] failed to carefully validate the tray she selected belonged to the resident in question. Additionally, she failed to utilize the identifier process [the resident wristband] to correctly identify resident [Resident #1] before giving Ms. [Named Resident #1] another resident’s tray .After giving the wrong tray, [Named CNA #20] exited the resident’s room to take a tray to another resident. Leaving the resident alone to eat should not have occurred, as resident [Resident #1] required assistance eating .[CNA #20 called for assistance when she reentered the room about ,d+[DATE] minutes later] Upon entering the room, the RN noted that Resident [Resident #1] was not responding to verbal commands and was not making any sounds .Floor staff were told to call 911 and bring the crash cart to the resident’s room Paramedics arrived at the resident’s room at 18:07 [6:07 PM] and exited the facility with the resident at 18:35 [6:35 PM] .At 20:00 [8:00 PM] the facility received notification the Resident [Resident #1] has [had] expired at the hospital .