Winter Haven Health and Rehabilitation Center has been cited by the Florida Agency for Healthcare Administration after a resident was found on the floor by a visitor, and nursing home staff failed to care for him. The resident had eaten a peanut butter and jelly sandwich, which he was allergic to, while left unsupervised. This resident had been using a gastronomy feeding tube for a while and was not meant to be left alone with a solid food, much less one that could cause an allergic reaction. The facility “failed to render assistance” after being notified of the resident’s condition, according to this citation report.
The resident had been assessed when he was admitted to Winter Haven Health and Rehabilitation Center. This documentation listed his moderately severe peanut allergy, limited mobility, and dependence on nursing staff for eating. The resident’s mental status had been evaluated as limited, and he was “rarely/never understood.” The resident also had a guardian due to developmental disabilities. The nursing home did order a speech therapy evaluation to help the facility create an accurate plan for this resident. The Speech Therapist, however, had not been able to help the resident; he was unable to follow commands due to developmental delays. In a previous group home, the resident had been given solid food, even though the staff at that facility knew that he was swallowing food into his lungs. Based on the resident’s past experience with speech therapy, the facility did not believe this would be helpful. At this point, the resident was already using a feeding tube, but the nursing home recommended a “swallow study for further assessment to determine [the] safest diet for him.”
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The swallow study was completed at the hospital to determine whether the resident would be able to eat without a tube, despite his habit of acting impulsively and grabbing for food. The swallow study showed that the resident “was confused and unable to follow one step commands.” The resident also demonstrated severe pharyngeal dysphagia, or a problem with swallowing because of an issue with the throat. The hospital believed the resident was at risk of “aspiration with hard solids due to oral deficits,” or taking food into the lungs while eating. The hospital’s report also noted that the resident was at risk of aspiration with thin liquids, even when given by spoon. The resident had a weak cough , leading to a high overall “risk of aspiration due to decreased airway protection.” The hospital’s swallow study recommended that the resident be given nutrition through alternative means.
Nursing notes showed that the resident was able to get out of bed, into his wheelchair, and self-propel down the hallways of the nursing home. The resident did need help with activities of daily living, such as bathing and getting dressed. The resident did stay in the dining room for most of the meal and was noticed attempting to take food off of the tables. When nursing staff were able to redirect or distract him, he would stop taking food. This was effective as a short-term measure. The nursing home staff did make the resident’s physician aware of the resident’s habit of taking food from the plates of other residents during a regular physician’s visit. The physician recommended that the resident be evaluated for occupational therapy after learning about this habit.
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The resident was in the dining room when a visitor noticed that he was unconscious and lying on the floor. It is possible that a resident who was given two peanut butter and jelly sandwiches gave one to the resident profiled in this citation. An emergency cart arrived two minutes later, leading to cardiopulmonary resuscitation (CPR) two more minutes later. The resident was a full code, which meant that he/his guardian permitted actions like cardiopulmonary resuscitation (CPR) in such a situation. Emergency services were called shortly after and arrived within ten minutes. The Director of Nursing, Administrator, and Supervisor were notified within a few minutes of the situation. Two hours after the resident was noticed by a visitor, the resident’s physician was notified. Family was notified as well, but there was no answer to the nursing home’s call. The facility’s worksheet did not match the emergency medical service’s report summary and was off by ten to fifteen minutes.
The emergency medical services report has a complete account of what the nursing home did to help the resident:
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Patient was eating a peanut butter and jelly sandwich and started to choke on it. Staff members stated he was allergic to it. Staff members stated he went unresponsive, had no pulse and CPR was initiated by staff. The patient was placed on a monitor and was asystole (a serious type of cardiac arrest). The first dose of [epinephrine] was given. The patient’s mouth was looked into, and he had peanut butter still in his airway. Laryngoscope and forceps were used to try to get some of the peanut butter out. His mouth was also suctioned, was only able to get some out. Second round of [epinephrine]was given. The patient went into ventricular fibrillation and then shock. CPR was continued. The patient was given the third dose of [epinephrine]. The patient was placed on the stretcher and placed in the ambulance. The patient was given the fourth dose of [epinephrine]. The patient was placed on an [epinephrine] drip, en route.
When the resident reached the emergency room, he was intubated to assist with breathing. The resident did not immediately improve and was noted as “critically ill.”
The state investigator continued to interview nursing staff, asking them how they responded to this incident. One Licensed Practical Nurse (LPN) was making rounds at the time of the incident and passed a staff member in the hallway, who told her about the resident. The LPN stated the staff member “was just walking down the hallway, no excitement. I have no earthly idea why [the staff member] was not rendering aid to a resident that may have been injured, incapacitated, lying on the floor.” The LPN rushed to the dining room, taking the resident’s pulse and grabbing his chart from a nearby nursing station to check the resident’s code status and ensured he received necessary care at that point. Subsequent interviews revealed that two staff members had found the resident but had not provided care.
Winter Have Health and Rehabilitation Center was cited because the state investigative team found that they “failed to ensure [the resident] was provided with the level of supervision needed to prevent access to orally consumed foods and ensuring non-oral means of nutritional support were provided,” as well as because “two staff members were made aware he was on the floor and did not render care and services creating a delay in emergency care.” The facility was also cited for a failure “to conduct a complete and comprehensive investigation for [the resident] who was found lying on the floor by a visitor.”
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