State Findings:
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review, staff and Ombudsman interviews, review of facility policy titled Enteral Nutrition revised (MONTH) 2014, and review of the Georgia Nurse Practice Act (chapter ,[DATE]) the facility failed to provide care and services in accordance with facility policies and that met professional standards related to providing a dinner tray to one resident (R) (R#1) with a Physician order to have nothing by mouth (NPO). Failure to provide services according to professional standards resulted in R#1 choking on food, aspirating, then a cardiopulmonary arrest and an eleven (11) day admission to an Intensive Care Unit, where he was maintained on life support, with an endo tracheal tube, then a [MEDICAL CONDITION], and remained unresponsive due to suspected [MEDICAL CONDITIONS]. R#1 was transferred to a Long Term Acute Care Unit (LTAC) where he expired twenty-seven (27) days later. The sample included ten (10) residents.
On (MONTH) 25, 2019 a determination was made that a situation in which the non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents.
The Administrator and the Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on (MONTH) 25, 2019 at 10:44 a.m. The noncompliance related to the Immediate Jeopardy identified to have existed on (MONTH) 22, 2019 when staff failed to follow the Physician’s orders for nothing by mouth (NPO) for resident (R) (R#1) who was newly admitted to the facility and was served a dinner tray which resulted in R#1 choking on a food item and R#1 went into [MEDICAL CONDITION].
The facilty had not provided a Removal Plan at the time of the exit on (MONTH) 29, 2019 therefore the IJ is ongoing. The immediate jeopardy is outlined as follows:
Resident #1 was admitted to the facilty on (MONTH) 22, 2019 with a feeding tube and written Physician’s orders to have nothing by mouth (NPO). Nursing failed to follow the physicians orders and served the resident a tray from the kitchen. Shortly after the tray was delivered R#1 was found to be in severe respiratory distress choking on a food item. The incident resulted in R#1 going into [MEDICAL CONDITION] and Cardiopulmonary Resuscitation (CPR) was started Emergency Medical Service (EMS) arrived and transported R#1 to the emergency room (ER) where R#1 was intubated and admitted to Intensive Care Unit (ICU) and later transferred to a Long Term Acute Care (LTAC) facilty where R#1 expired on (MONTH) 2, 2019.
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