**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide safe, appropriate monitoring/supervision/interventions for a resident that had a physician order for NPO (non-per-oral/nothing by mouth) from being fed by family member(s), resulting in an Immediate Jeopardy for one (R53) out of six residents reviewed for accidents. R53 was sent to the hospital on at least two occasions (7/10/23 and 7/12/23) for a decrease in oxygen saturation after being fed by family member(s) and the likelihood of possible aspiration, choking and/or other negative consequences. This deficient practice placed all residents with a NPO order at high risk for further safety concerns, significant harm, injury and/or death. Findings include: Immediate Jeopardy (IJ): The IJ began on 4/29/23. The IJ was identified on 7/13/23. The Administrator was notified of the IJ on 7/13/23 at approximately 10:56 AM and a plan to remove the immediacy was requested. The immediacy was removed on 7/13/23 at approximately 3:41 PM based on the facility's implementation of an acceptable plan of removal as verified on site by the survey team. Although the immediacy was removed, the facility's deficient practice was not corrected and remained isolated with potential for more than minimal harm that is not immediate jeopardy due to sustained compliance that has not been verified by the State Agency. On 7/11/23 at approximately 10:03 AM, R53 was observed lying in bed. By the resident's side was a tube feeding pole. No tube feeding was running at the time of the observation. The resident was alert, but not able to answer any questions asked. An initial review of the resident's clinical record was conducted on 7/11/23 and revealed R53 was initially admitted to the facility on [DATE] with diagnoses that included: Parkinson's disease, cerebrovascular accident (CVA), epilepsy and dysphagia (difficulty swallowing). A review of the resident's Minimum Data Set (MDS) assessment dated [DATE] noted the resident was severely cognitively impaired, required extensive one to two person assist for most activities of daily living, and received nutrition via a feeding tube. Continued review of R53's clinical record noted, in part: Order (6/22/23): NPO Diet. NPO texture related to Dysphasia following cerebral infarction. Nutritional Data Collection/Evaluation (6/27/23): .Resident is NPO with Osmolyte 1.5 via pump per PEG (Percutaneous endoscopic gastrostomy) @85 mL (Milliliters)/hr (Hour) x 18 hours per day to provide 1530 mL . Care Plan: Focus: The resident needs ADL (Activities of Daily Living) living assistance related to CVA diagnosis, Epilepsy, dysphasia .dependent on staff .Interventions: .Eating NPO (date initiated 3/30/23) . Care Plan: Focus: The resident is at risk for nutritional decline .receives 100% via formula. NPO status in place. Resident's family is known to bring in foods from outside even though resident is NPO, family has been educated multiple times .Interventions: Residents family is known to bring in foods from outside even though resident is NPO, family has been educated multiple times (5/2/23) . Care Plan: Focus: The resident has a potential psychosocial well-being problem r/t (related to) family not understanding disease process and diagnosis, mother states she gives him bites of pudding even though resident is NPO .Intervention: Educate family on risk vs benefit on not adhering to NPO order, including aspiration pneumonia, hospitalization and other further complications (3/30/23) . Progress Notes included: 4/27/23: Enteral Review: .Current PO order: NPO . 4/29/23: Nurses' Notes: .resident mother told care team member she fed him a baked potato and eggs . (Authored by Nurse J) 4/30/23: Nurses' Note: resident mother observed preparing to feed him .was asked to not feed him due to NPO status at that time she stated that she will speak to director regarding the issue . (Authored by Nurse J). 5/1/23: Nurse's Note: Writer spoke to resident's mother in regards to feeding resident food by mouth. Resident has trach and impaired speech/swallowing ability. Resident is an aspiration precaution is not able to form words. Resident's mother educated to NPO status, PEG tube feeding, Speech therapy evaluation, and the importance of healthcare compliance. Resident's mother continued to see no issue with her feeding the resident despite education . (Authored by the Director of Nursing/DON). 6/20/23: Nutrition-Hydration: .Interventions: NPO diet . 7/6/23: Nutrition-Hydration: .resident was readmitted .Interventions: NPO diet . 7/10/23 (3:00 PM): Patients family came in and against advice .fed him pureed foods. (Authored by Nurse K). 7/10/23: Nurse's Note: Patient was having trouble breathing. O2 (oxygen) at 80-84% not improving. MD (Medical Doctor), DON aware and family notified by message. Pt (Patient) otherwise alert and no extreme distress but does c/o (complain of) of SOB (shortness of breath) and lung sounds coarse all fields with wheezing . 7/12/23: Nurses' Note: Patient family keeps coming in and feeding patient against the advice of nurse. Patient later experienced wheezing and was in need of breathing treatment . 7/12/23: Nurses' Note: Contacted the Dr. Waiting on response. 911 called. 7/12/23: Social Service General Note: .Situation-New, follow-up, ongoing: Regarding outside foods.writer contacted (name redacted) R53's mother @ 4:30 PM today to set up a follow-up care-conference on Friday @ 10:30 .education or services provide: family has been educated on feeding patient puree food only . On 7/12/23 at approximately 3:10 PM, R53 was not observed in their room. On 7/12/23 at approximately 3:18 PM an interview was conducted with Nurse K. When asked as to where R53 was, Nurse K reported that he was sent to the hospital. When asked why, Nurse K reported that the family had come to the facility and fed the resident. Nurse K stated that after feeding the resident his O2 states dropped, he was wheezing and the physician ordered him out to the hospital. When asked if they were aware that R53 had an order for NPO, they reported that they were aware. Nurse K further stated that the resident's mother seemed to ignore the order and education provided to them. When asked if they knew what the family member fed to the resident, they stated they knew that the resident received cookies and milk but did not know any other food that was fed to him. Nurse K was asked if they were aware of this happening prior to 7/12/23, they noted that the same thing happened on Monday (7/10/23) and the resident was sent to the hospital again after his O2 levels decreased and he was wheezing. Nurse K reported that they informed the DON of what had happened. When asked about the education provided to them and the family, Nurse K reported that they were aware the resident was NPO and they had not provided any food/drinks to the resident. With respect to the family, Nurse K noted that the family had been instructed several times not to feed the resident and were uncooperative. Nurse K further noted that they were fearful that the resident's mother also brushed the resident's teeth with toothpaste and had him swallow water. On 7/12/23 at approximately 3:30 PM, a phone interview was conducted with the Speech/Language Pathologist (SLP L). SLP L reported that they are not employed by the facility and was hired to work as needed until the facility hired a full-time speech therapist. SLP L was asked if they worked with R53 and whether they were aware of the resident's family history of feeding the resident even if he is NPO. SLP L reported that they had completed a review of the resident's record and before they started working with him, they ordered a swallow study. According to SLP L the Swallow Study recommended a trial for thin liquid and pureed food. After the study SLP L stated they started to work with R53 by providing a half teaspoon of water and providing small bites of apple sauce and pudding. SLP L stated they wrote up a plan for R53 and had the family come in as they watched how they fed the resident. SLP L reported that on or about 6/29/23, the family was present in the building and watched as they fed R53 2 ounces of applesauce and a small sip of water with a spoon. The resident was in an upright position as he was being fed. SLPL stated that on 6/29/23 they asked the family to continue to wait before they fed the resident. SLP L reported that the last time they saw R53 was on 7/3/23 and he consumed strawberry apple sauce with a small spoon and water with a teaspoon. SLP L stated that on 7/6/23 they were asked to come to talk with the family because the DON needed to be in agreement with the family. They indicated they talked with the resident's sister and the DON and informed them that the only time the resident could eat was if he was in an upright position. At that time they thought it was acceptable to allow the family to provide pureed food and thin liquid. SLP L reported that R53's sister asked if they could bring in ice cream and Vernor's soda and baby food with curry. They stated that they told the family no meat and the resident nodded their head indicating they did not want curry. SLP L indicated that they believed the family had a clear understanding of what could be provided to the resident. However, SLP L stated that they had recently been informed from the DON (approximately one hour prior to the interview) that the family had provided unapproved food and the resident was sent to the hospital. When asked about the food provided to the resident on 7/10/23, SLP L reported that they were not aware that the family had provided food to the resident or that the resident was then sent to the hospital. A follow-up phone call was made with SLPL on 7/12/23 at approximately 4:25 PM. SLP L was asked where in R53's clinical record would the surveyor be able to view their notes pertaining to the resident. SLPL recommended obtaining the documents from either the Administrator or the therapy department. SLP L was also asked as to whether they had any contact with R53's treating Physician (hereinafter Dr. N) regarding allowing family to provide food to the resident. They were also asked if the treating physician had changed the resident's NPO order. SLP L stated that they never had any contact with Dr. N. On 7/12/23 at approximately 4:26 PM, Physical Therapy Staff M provided SLP L's notes. The notes were reviewed and documented, in part, the following: 6/27/23: .PEG tube provides nutrition. Therapeutic trials by SLP L educated the patient's nurse regarding the results of the MBSS (Modified Barium Swallow Study), recommended for trials by SLP .Pt. tolerated 10 small bites of pudding .oral movements were slow and labored .required verbal cues to move the pudding to the back . 6/29/23: .Patient was seated on the edge of the bed .His mother, sister, brother and niece were present for the Dysphagia treatment session. SLP provided education .Family was educated that only therapeutic feeding with SLP are approved at this time, family was asked not to feed him liquids/solids until SLP provides approval .Family offered to bring in some of patient's favorite foods, such as curry .for the SLP to use during sessions . 7/3/23: .Patient was difficult to understand when he spoke more than one word .Patient tolerated 1.5 oz of thin liquid .he required verbal cues 50% of time .Patient tolerated 2.5 oz of applesauce with tsp .His swallow trigger was delayed between 1-5 seconds; verbal cues to move food back of mouth and swallow .Provided instruction to patient with nursing staff in safe swallow strategies specifically, only therapeutic feedings with SLP, family may not feed patient at this time (emphasis added) . *There were no further documents provided by Staff M that noted SLP L had met with the resident, facility or resident family. On 7/13/23 at approximately 4:00 PM, a single sheet of paper from SLP L was provided that documented only one sentence as follows: Missed visit #1 for R53 on 7/6/23. Consulted with DON and called family to communicate that it is acceptable for him to enjoy PUREE FOODS and THIN LIQUIDS by cup or spoon when upright. No straws. Prefer patient is seated in a w/c (wheelchair) or side of bed for oral intake. DON to educate nursing staff. On 7/12/23 at approximately 4:39 PM, a phone interview was conducted with Dr. N. Dr N reported that she was familiar with R53 and the family. Dr. N was asked if they were aware that R53's family was feeding him even though they had issued an order for NPO. Dr. N reported that they were aware that the family had attempted to feed the resident in the past. They indicated that R53 had under gone a swallow study and had been working with SPL L on a specified pureed diet however, the NPO order had not been changed. When asked if they felt the family member could feed the resident, Dr. N reported no not until there was additional training and they were assured that they were following an ordered care plan. On 7/13/23 at approximately 8:41 AM, an interview and record review were completed with the DON. The DON was queried as to R53 and his family who continued to feed the resident even though he was still NPO. The DON reported that the family was found feeding the resident food by mouth a few months ago even though the resident was NPO. The DON indicated that the family was providing solid food to the resident and was educated not to do so as it was a risk to the resident. When asked about the two dates (7/10/23 and 7/12/23) that noted the resident was fed again by family members and subsequently sent to the hospital, the DON reported they were aware of both incidents. The DON also reported that the Hospital reported that they were aware family was feeding R53 despite NPO status. When asked what the facility did after they discovered the family was feeding food to the resident, the DON reported that they had set up a care conference meeting with the family on 7/14/23 to educate the family again on not feeding the resident. The DON was asked to provide hospital records for R53, including, but not limited to 7/10/23 and 7/12/23. On 7/13/23 at approximately 10:24 AM, a phone interview was conducted with family member (FM) O. FM O reported that the resident had been at the facility since March 2023. They noted that they had concerns about the air quality at the facility and the resident's cough. FM O was asked if they were aware of the resident's NPO order. FM O reported that the resident had been evaluated by the Speech Therapist and the family was told that R53 was on a soft diet and could be fed unsupervised if they used a small spoon. When asked about the foods they fed to the resident, FM O reported that yesterday (7/12/23) they fed R53 whipped potatoes and a sweet potato. They also noted that they were given milk by the facility and they poured the milk on top of a Windmill cookie. When asked if they were aware the facility knew what they had fed to R53, FM O reported that they were not sure, and stated that they went into the room to feed the resident and he then had a hard time breathing and the staff came in and gave him oxygen and then he was sent to the hospital. FM O noted that at the hospital they thought it was just a cough. They reported they knew the facility thought that he had aspirated, but the two times that happened, they thought it was just a respiratory issue. On 7/13/23 at approximately 11:48 AM, an interview was conducted with Nurse J. Nurse J was queried as to R53 being fed by family members. Nurse J reported that they were aware the resident was NPO and that the family had brought food in the past and continued to do so. Nurse J noted that they were aware that speech therapy had started feeding the resident and was not certain whether family was allowed to do so on their own as they had been off work for a few days. When asked if they had been trained to work with the family regarding feeding, Nurse J reported that if we noticed the family was feeding the resident they would try to redirect them, however it was often they would not listen. On 7/13/23 at approximately 2:40 PM, the Administration interview was interviewed. When asked if they were aware family had been bringing food into the facility and feeding R53 who was NPO, the Administrator reported that the issue had not initially been brought up in QA (Quality Assurance) meetings. The Administrator reported that they became aware of the concern after R53 had completed their swallow study and the family wanted his peg tube removed. On 7/13/23 at approximately 2:41 PM an interview was conducted with RD Q. RD Q reported they started working at the facility in February 2022. When asked about R53's swallowing and nutritional Status, RD Q reported that to her knowledge the resident was still NPO and they were working with the resident via feeding via a peg tube only. When asked if they were aware that R53's family had been feeding them food, RD Q reported they were not made aware until today (7/13/23). Additional requests were made to the DON to provide hospital records for R53. The DON reported that they were not able to retain any records pertaining to the swallow study and emergency department (ED)/hospital records with the exception of the following: 3/28/23: Medication Discharge Report *This report contained only medication to continue being taken by the resident. 6/22/23: Medication Discharge Report. *This report contained only medication to continue being taken by the resident. 5/31/23: Patient Discharge Instructions: Discharge Diagnosis: Aspiration pneumonia. *This report did not contain any notes from the hospital or detailed instructions. 7/12/23: Discharge instruction: I spoke with the patients mother. He has a history of asthma and was previously on Advair and Singular .please consider this cough may be related to underlying asthma . *This report did not contain any further notes from the ED. A review of the facility policy titled, Accidents and Supervision (revised 8/11/22) noted, in part: Policy: .Accident: refers to any unexpected or unintentional incident, which results in injury or illness to a resident .Risk refers to any external factor, facility characteristic (e.g. staffing .) or characteristic of an individual resident that influences the likelihood of an accident .Policy Explanation and Compliance Guidelines: The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents .Identification of Hazards and Risks .All staff .are to be involved in observing and identifying potential risk of resident having an avoidable accident .the facility should make a reasonable effort to identify the hazards and risks in the resident environment .these sources may include, but are not limited to: i. Quality assessment and assurance (QAA) activities .Medical History .Physical exam .facility assessment .individual Assessment .Evaluation and Analysis- the process of examining data to identify specific hazards and risks and to develop targeted interventions to reduce the potential for accidents .Both the facility-centered and resident-directed approaches include evaluating hazard and accident risk data, which includes prior accidents/incidents, analyzing potential causes for each hazard and accident risk, and identifying or developing interventions based on the severity of the hazards and immediacy of risk .Implementation of Interventions-using specific interventions to try to reduce a resident's risk from hazards in the environment. The process includes: a. Communicating the interventions to relevant staff. b. Assigning responsibility. c. Providing training as needed. d. documenting interventions .e. ensuring interventions are put into practice .g. Developing of interim safety measures may be necessary if interventions cannot immediately be implemented fully. h. Facility based-interventions may include but are not limited to: i. Educating Staff .i. Resident-directed approaches may include: 1. Implementing specific interventions as part of the plan of care. ii. Supervising staff and residents .Monitoring and Modification - a. Ensuring that interventions are implemented correctly and consistently. b. Evaluating the effectiveness of interventions. c. Modifying or replacing interventions as needed. d. Evaluating the effectiveness of interventions. 5 Supervision: Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Adequacy of supervision: a. Defined by type and frequency. b. Based on the individual resident's assessed needs and identified hazards in the resident environment . Removal Plan for IJ for F689: The facility identified the resident R53 was being fed by family on 4/29/2023, while the resident had NPO orders, the family was educated that they could not feed resident while NPO order was in effect and family continued to bring in food. The following were implemented immediately as listed below: - A Licensed Nurse examined resident #53 on 7/13/23. No adverse effects were found. - On 7/13/23, the Registered Dietitian (RD) audited all NPO residents to ensure accuracy, audited if any resident are receiving food or drink while on NPO diet and ensure care plan matches NPO status. - On 7/13/23, the Resident's family members were informed that they are not allowed to bring in food inside the facility and assist resident with meals while resident is NPO status. The Family members are also notified that all visits will be in the common area and in if they continue to feed the resident, all future visits will be supervised and/or visits will be suspended. The Guardian agreed to the terms on 7/13/23. - The receptionist at the front door will ensure R53 Family members do not bring food into the facility between the hours of 7am-8-pm, Nurses will oversee the 8pm-7am. - Facility started education with staff on 7/13/23 to include: - What is NPO Diet - Where to find diet order - If your unable to find a Diet order contact the nurse or RD - If the resident or visitor is not following diet orders what are the next steps - As of 7/13/2023, 18 of 36 Clinical staff have been educated. No nurses or Certified nurse aides will work without receiving education. - An AD Hoc QAPI (quality assessment and improvement performance) was held on 7/13/23. - Beginning on 7/13/2023, DON/Designee will audit new NPO diet orders M-F to ensure diets are being followed per the physician order. The RD and Unit Manager will round during meal to ensure compliance.