ALBUQUERQUE, NM Resident’s death likely caused by staff not monitoring/watching the resident more closely when staff had been aware of his behavior.

Based on record review, interview, and observation the facility failed to provide adequate supervision for 2 (R #s 1 and 24) of 12 (R #s 1, 2, 3, 4, 5, 6, 7, 8, 14, 19, 24 and 25) residents reviewed for accident hazards. This deficient practice likely resulted in:

R #1’s death, by staff not monitoring/watching the resident more closely when staff had been aware of his behavior.

R #24 smoking in his room If staff are not monitoring and watching residents more closely, than avoidable accidents, causing harm or death to residents will continue to occur. The findings are:

Findings related to R #1:

[NAME] Record review of the Nutritional assessment dated [DATE], indicated that R #1 was on a regular, liberalized diet and the diet texture was Dysphagia puree (food blended smooth with no lumps or particles).

Record review of R #1’s facesheet indicated that resident was admitted to the facility on [DATE] had a [DIAGNOSES REDACTED].

Record review of the menu for Saturday ([DATE]) revealed that hot dog on a bun was served.

Record review of a nursing progress note dated [DATE] indicated that at 1:30 PM, R #1 was noticed to be choking walking from the kitchen very frantic. A dinner roll was in his mouth not chewed well. This resident is on a pureed diet and not to have whole foods. (Name of nurse) started the [MEDICATION NAME] maneuver (a first aid procedure used to treat upper airway obstructions (or choking)) without success. Resident loss (sic) consciousness we helped him to the floor. 911 was called and dispatched. (Name of nurse) and myself (Name of nurse) started Cardiac [MEDICAL CONDITION] Resuscitation(CPR) withoxygen delivery and suction, trading chest compression’s with other certified employees. After roughly 15 minutes (Name of) Ambulance and Fire department took over. (Name of Physician’s Assistant (PA)) on call and called and notified of the 911 call. 2:28 PM CPR was stopped and Resident was moved into a private room and POA (Power of Attorney) (Name of POA) was called and notified. (Name of), RN (Registered Nurse) Unit director was called and notified she came to and pronounced. 3:00 (PM) OMI (Office of the Medical Investigator) notified they are to be picking up the body.

On [DATE] at 9:29 am, during an interview with Unit Manager (UM), she stated that she became aware of the situation at 2:13 pm when she received a phone call from RN #1, Emergency Medical Services (EMS) was still working on R #1.

F. On [DATE] at 9:44 am, during an interview with the Center Nurse Executive (CNE), she stated that she received a call about R #1. She was given information on what was currently happening. She was informed by staff that he R #1 had chocked on a hot dog (with bun) and staff and EMS were unable to save him. She stated that she immediately began looking into how R #1 had eaten a hot dog, since he was a puree diet only. The CNE stated that what she discovered was that the lunch plates were still on the dining room trays in the dining room, the doors to the dining room were always open on that side of the dining room. She stated that R #1 had wandered back into the dining room and ate a hot dog off of another residents plate that had not been picked up. He began to choke and walked towards the nursing station grabbing his throat like he couldn’t breathe. Staff tried to clear his throat and did get some of the food out. RN #1 began the [MEDICATION NAME] on R #1 but after around three thrusts R #1 passed out. They lowered him to the floor and began CPR and suctioning. Emergency Medical Services (EMS) was called and when they finally arrived they took over. They were able to clear his airway and intubate (insert a tube into a person or a body part, especially the trachea for ventilation) him, but they were not able to save him and R #1 passed away.