Pruitthealth in Moncks Corner, SC, was cited after the facility failed to review and revise the care plan for a resident who was known to put non-edibles in her mouth. This resulted in the resident trying to eat a vinyl glove, which got stuck in her throat. Nursing staff found the resident unresponsive and ultimately could not revive her.
According to the facility’s notes, the resident had “short-term and long-term memory problem[s] with impaired cognitive skills for daily decision-making.” The resident also suffered from dementia and “was known to eat napkins,” according to the Director of Nursing (DON). The investigator reviewed the resident’s care plan and noted there were no plans in place regarding the resident’s tendency to eat non-food items.
The day the incident occurred, a member of the resident’s family visited the resident at the facility. The Nursing Home Administrator (NHA) stated the family member fed the resident and was the last one to see the resident before she was found unresponsive by a CNA. Interviews with staff members revealed that the family member had worn vinyl gloves while assisting the resident with dinner; one glove was left next to the resident. An LPN had observed the glove sitting on a table next to the resident but did not remove it from the room.
When the CNA entered the resident’s room and noticed the resident wasn’t moving or breathing, she did a sternum rub but did not get a response. According to the CNA’s note, “vital signs were absent with no breath sounds and pupils fixed. Hospice notified of the change in the resident’s status.” The hospice nurse and facility nurse went to the resident’s room. The facility nurse decided the staff needed to check the resident’s mouth for any food that may be stuck in her throat.
Upon inspection, the nurses found “something sticking out of her throat and staff pulled it out of the resident’s throat and it was a vinyl glove.” According to the facility’s follow-up report, the facility was notified by the police that the preliminary cause of death was noted as Dementia and that it remained unclear whether the glove played any role in the death.”
Issues with the care this resident received ultimately cost the resident her life. One of the basic steps to caring for a resident is consistently reviewing and revising a resident’s care plan. This ensures all staff members know of and can respond to behavioral issues displayed by the resident. The resident in this citation was known to chew on cloth napkins. However, this information wasn’t documented. Therefore, staff members who were assigned the resident but weren’t familiar with her “impaired cognitive skills” had no idea they should remove non-edible items out of the resident’s reach.
In addition, the LPN who observed the glove sitting on the table near the resident did not remove it when she went by the room, even though she stated she “made sure that the staff knew the resident chewed on cloth dinner napkins and to keep things the resident could put in her mouth out of reach.” A nurse from a different unit was assigned to the resident that evening, meaning she was not familiar with the resident’s tendency to eat foreign objects.
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