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Based on medical record review, policy review, and staff interview, the facility failed to ensure staff communicated and assessed the dietary needs of a patient to prevent a choking episode. This affected one (Patient #2) out of four records reviewed. (A0395) The cumulative effects of these systemic practices resulted in the agency's inability to ensure patient care needs would be met.

Based on medical record review, policy review, and staff interview, the facility failed to ensure staff communicated and assessed the dietary needs of a patient to prevent a choking episode. This affected one (Patient #2) out of twelve records reviewed. The facility's active census was 113.

Findings include:

The medical record revealed Patient #2 presented to the hospital on 07/25/24 from a local emergency department for constipation. Additional diagnosis included autism and down syndrome. The patient was non-verbal. The first note in the medical record for Patient #2 was from the admission nurse (Staff H). This note stated the patient came to the hospital on 07/25/24 at 9:27 PM from an outside emergency department and was a direct admit to Room 605. Nursing notes at 10:20 PM stated the caregiver from the group home informed the nurse to give his pills crushed in applesauce/pudding and the patient eats a pureed blended diet with thin liquids. Nursing notes indicated information was gathered from the caregiver and the binder provided from the Group Home. No documentation was found of any swallow test completed upon admission or of communication note to indicate the prescribing providers were informed of the need for a pureed diet.

The history and physical (H&P) was completed on 07/26/24 at 10:04 AM by Staff G. The H&P documented no diet was ordered. Physician notes further stated the group home manager was called with a message left.

On 07/26/24 at 10:00 AM the nurse practitioner (NP) ordered a regular diet. A regular diet was provided and consumed by Patient #2 on 07/26/24 at 1:00 PM and 5:00 PM and with each meal on 07/27/24. Documentation revealed Patient #2 consumed 100 % of each of these meals. Documentation on 07/28/24 during the lunch meal revealed a rapid response was called due to Patient #2 choking on pizza.

The rapid response notes of 07/28/24 stated the team was paged at 12:21 PM. Respiratory staff were at the bedside at 12:21 PM and the physician at 12:22 PM. The notes stated Patient #2 choked due to eating too fast. The Heimlich was completed with the patient dislodging the food and vomiting. An x-ray was ordered, completed at 12:53 PM with no results of broken ribs or other issues.

Interview with the NP (Staff O) who ordered Patient #2's diet was completed on 11/06/24 at 12:15 PM. Staff O stated when ordering a diet the bedside nurse will do a swallow test then reach out for a diet. Staff O stated the staff did not inform her the patient required a pureed diet and she did not ask if there were any modifications needed. Staff O stated she was made aware Patient #2 choked after the incident.

Interview on 11/06/24 at 3:00 PM the nurse who completed the Heimlich maneuver (Staff I) stated stated Patient #2 had eaten breakfast without a problem. Staff I set him up for lunch, he took a bite of the mac/cheese and had no issues. When he ate a bite of pizza he started choking. Staff I attempted to get him up and couldn't so they climbed in the bed and completed the Heimlich and called a rapid response.

Interview on 11/07/24 at 7:30 AM, the admitting nurse (Staff H) stated Patient #2 arrived to the unit with a caregiver from the group home and had a binder with him. Staff H went thru the admission questions and found out he needed his pills crushed and a pureed diet. She relayed this to the NP when they came into examine him. The patient was nothing per mouth (NPO) thru the night. Staff H put a note in the record stating he required a pureed diet when ordered. Staff H stated this information was passed on to the night NP and also passed on in report the next day. Staff H stated they did not do a swallow test due to this patient being combative on admission and not cooperative.

Review of the facility policy titled "Admission Assessment and Interdisciplinary Screening Consults Standard Operating Procedure," dated 099/13/23, revealed the policy instructs the registered nurse (RN) to complete a nursing admission assessment within 24 hours of admission. This assessment will identity risk factors per patient screenings to refer to the appropriate caregiver professional and or physician. Information gathering uses multiple methods including but not limited to: verbal, available health records, patient and/or significant others/caregiver, observational and overall physical assessment findings and clinical knowledge. Initial admission assessment components are not limited to vital signs, weight, skin, falls, pain, communication/language/sensory needs and dysphasia swallow screening assessments.

Interview on on 11/06/24 at 4:50 PM, Staff A verified the facility did not follow the policy to identify the dietary needs of Patient #2, who was provided the incorrect diet which led to a choking episode.