SAN ANTONIO, TX – RIVER CITY CARE CENTER

Based on observations, record reviews and interviews the facility failed to ensure the resident environment remained as free of accident hazards as possible for 1 of 21 residents (Resident #1) reviewed for care, in that:

(a). Resident #1 had choked on [DATE], no interventions were implemented. Subsequently Resident # 1 choked again on [DATE] resulting in death.

(b). The facility failed to identify residents who grabbed food and were at-risk for choking, for ensuring snacks were not left within residents’ reach, and have a process for hydration aides to verify residents’ diets when handing out snacks

These failures resulted in identification of Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed [DATE], the facility remained out of compliance at a level of actual harm with a scope identified as a pattern until interventions were put in place for all residents at risk of choking.

These deficient practices could affect residents in the facility who are at-risk of choking, and place them at-risk for harm, choking or death.

During an interview on [DATE] at 1:25 PM with RA G she revealed Resident # 1 did have a history of grabbing food if it was left out or from the trash can. She further revealed he would not go into other residents’ rooms.

During an interview with the MDS Coordinator on [DATE] at 8:25 AM, the MDS Coordinator confirmed there were no interventions placed after Resident #1 returned from the hospital from choking on [DATE]. The MDS Coordinator stated that to her knowledge there were not any records of Resident #1’s non-compliance with his diet being monitored by facility staff.

During an interview with the Administrator on [DATE] at 9:45 AM, the Administrator stated that he had not been informed by facility staff of Resident #1’s previous choking incident on [DATE] until yesterday, [DATE]. The Administrator stated that had he been made aware of the resident’s incident on [DATE] he would have reported the incident, and further stated, communication in this building was non-existent. The Administrator further stated that following Resident #1’s previous incident the first thing he would have done would have been to review the resident’s care plan to see if interventions were in place. Further interview with the Administrator revealed they have not had a QA meeting and that they began to complete 24 hour reports two weeks after he started His primary focus since starting in (MONTH) (YEAR) had been on cosmetics of the building and care of residents. The Administrator further revealed they were having difficulties transitioning from one corporation to the current corporations as a lot of the staff had to be termed due to not meeting the current corporations’ standards. He further stated they were having difficulty obtaining employee training records.