HospitalInspections.org

Based on closed medical record review and staff interview, the facility nursing staff failed to provide nursing supervision by failing to ensure a patient received a safe mechanical diet and failing to report a patient change in condition for 1 of 10 sampled patients (#8).

The findings include:

Review of closed medical record of Patient #8 revealed an 86 year old female with a medical history of dementia, COPD (chronic obstructive pulmonary disease - progressive disease that makes it hard to breathe), and hypertension (high blood pressure). Patient #8 was a DNI/DNR (do not intubate - tube in windpipe to assist with breathing / do not resuscitate) on Hospice care (care that focuses on the palliation - comfort care - of a terminally ill patient).

Review of the ER (emergency room) Physician Documentation for 10/17/2015 at 1224 by (MD (medical doctor) #1) revealed "...History Present Illness...History Source: Patient, EMS (emergency medical services), EMS notes reviewed, RN (registered nurse) notes reviewed, VS (vital signs) reviewed, pulse ox results reviewed ...Review of Systems:...ENT:...Negative difficulty swallowing..." Review failed to reveal any reference to documents from the ALF (Assisted Living Facility) as source of information.
Review of the admission history and physical documented on 10/17/2015 at 1338 by (MD #2) revealed the following "...Most of the history is obtained from the ER (emergency room) notes and patient's son at the bedside...the patient is on hospice care...Past Medical History...Gastrointestinal: Gastroesophageal Reflux, Cholecystectomy (removal of the gall bladder) Appendectomy (removal of the appendix)...Exam: Gastrointestinal Assessment: Soft, Nondistended, Positive bowel sounds, ..." Based on the medical record, there was no documentation of information obtained from the family on Patient #8's diet, feeding or swallowing ability.
Review of physician admission orders revealed the following order: 10/17/2015 at 1424 by MD #3 - General Healthful diet (regular diet) and NPO (nothing by mouth) after midnight (in preparation for surgery on 10/18/2015).
Review of a medical/surgical unit nurse's admission physical assessment note, on 10/17/2015 at 1640 by RN #2, revealed "...GI symptoms...difficulty swallowing, Gastrointestinal Assessment comment...pureed diet as per daughter..."
Review of physician orders 10/17/2015 at 1715 by MD #2 revealed "General Healthful diet, Diet Modification: pureed..."
Further review nursing documentation by the nursing assistant (NA (nursing assistant) #1) on 10/17/2015 at 1739 revealed "...lunch, percent consumed 50%, diet tolerated - fair...pt (patient) resting...oral amount - 120 ml (milliliters) liquid..."
Review of a nurse's note on 10/18/2015 at 0409 revealed "...Interventional Summary / Patient Note: patient tolerated medications well...NPO (nothing by mouth) status has been initiated. No distress noted..."
Review revealed the patient went to the OR (Operating Room) on 10/18/2015 at 0730 for an ORIF (open reduction / internal fixation) of her hip fracture. Review revealed patient #8 returned to the med/surg unit at 1000 and RN #6 was assigned care for Patient #8.
Review of Physician #3's post-op orders on 10/18/2015 at 1042 revealed "General Healthful diet." Review of this order failed to reveal a modification for pureed diet.
Review of NA #3 (nursing assistant) documentation revealed patient #8 was confused, trying to get out of bed, and pulling at IV (intravenous) lines upon returning to the unit after surgery. Review of unit manager documentation revealed the patient was on 1:1 surveillance with a sitter in her room from 10/18/2015 at 1530 through 10/21/2015 at 0700.
Review of NA #3 documentation 10/18/2015 at 1447 revealed 80 ml of liquid intake, and lunch 25% and oral intake 120 ml liquid at 1719.
Review of a Daily Physical Assessment note by RN #3 on 10/18/2015 at 2030 revealed "...lung sounds - bilateral rhonchi (coarse rattling respiratory sounds, usually caused by secretions in the airway) ...patient encouraged to cough and deep breathe..." Review of a patient note by RN #3 on 10/18/2015 at 2130 revealed "called to patient's room via (NA#2) CNA (certified nursing assistant). Patient O2 (oxygen) sats in low 70's (with normal values being >90%). Increased O2 to 5 l (liters/minute) and attempted to suction mouth. Patient has been coughing but holding stuff in mouth. (RT (respiratory therapist) #1) notified."
Review revealed a note documented by RT #1 on 10/18/2015 at 2145, which stated "...(RN #3) called and stated that patient's sat's (oxygen level) were in the 70's (normal values are between 90-100). Upon entering room, patient was on 5 l/min NC (5 liters of oxygen by nasal cannula) and sat's were 71%, at 2145 placed patient on 50% venturi mask, sat's increased to 83%, at 2151 (6 minutes after drop to 71%) placed patient on 100% nonrebreather, sat's increased to 94% . RT will continue to monitor patient." Review revealed patient vital signs on 10/19/2015 at 0129: temperature 97.4, pulse 85, respirations 16, oxygen sat 95%. Review further revealed an RT note by (RT #2) on 10/19/2015 at 0741, which stated "upon entering room pt on 100% NRB (nonrebreather) with SpO2 (oxygen level) 100%. Titrated to 50% venturi mask with sats maintaining at 99%. Continued to gradually wean pt's O2, pt. maintained at 98% on 3 l/min NC. (RN #4) made aware."
Review of an NA (nursing assistant) Activities of Daily Living note on 10/19/2015 at 0832 revealed "...breakfast percent consumed 25%, diet tolerated fair..."
Review revealed nurse notes by (RN #4) on 10/19/2015 "...0925 patient strangled on water with pills this morning. Will keep NPO for now until seen by doctor...0935 O2 sats 47% on 3 L. course rhonchi to lungs. (MD #4) paged. He states he is coming to see patient. RT has been notified and in room...0945 O2 sats 84%. RT has suctioned...0955 - RT deep suctioned patient with moderate amount of creamy/white thick secretions. O2 sats increased to 89%...0956 (MD #4) in to assess patient. orders given. O2 sats 97%. breath sounds improved. expiratory wheezes heard..." Review revealed a physician order on 10/19/15 at 0945 "npo" (nothing by mouth).
Review further revealed the patient was diagnosed on 10/21/2015 by MD #5 with acute on chronic hypoxic respiratory failure secondary to aspiration pneumonia, and COPD with acute exacerbation secondary to aspiration episode, and her condition worsened and she expired on 10/27/2015 at 1930.
An interview conducted with RN #2 on 6/29/2016 at 1330 revealed "I vaguely remember this patient. The daughter told me that the patient was on a pureed diet at the ALF. I would have charted if someone told me the patient was on thickened liquids and that would have been ordered..."

An interview with the Accreditation Coordinator on 06/29/2016 at 1500 revealed that in the electronic medical record system used by the facility, all previous diet orders are not visible when placing a new order - only the most recent order is visible. "...For this patient (#8), the previous order was for NPO in preparation for her hip surgery..."
An interview with the Administrative Director #1 on 06/29/2016 at 1515 revealed that the pureed diet should have been reordered when the patient returned from the operating room.

NC00118240