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Based on document review and interview, it was determined the facility staff failed to ensure one (1) of twelve (12) patients (Patient #2) received the correct information at the time of discharge related to diet.

The findings include:

Patient #2 was a random patient identified as a fall risk seen during the tour of the 4th floor. Patient #2 had previously been admitted on 9/11/17 and discharged on 9/16/17. At the time of discharge Patient #2 and spouse were given discharge diet instructions which documented Patient #2 was to "Return to previous diet". During this hospitalization Patient #2 was placed on ground food with nectar thickened liquids.

Patient #2's spouse stated, "I asked them (the nurse discharging Patient #2) twice are you sure he/she can return to his/her previous diet and they said yes. I am sure eating a regular diet caused him/her to aspirate again and here we are."

Patient #2 was admitted on 9/23/17 after being seen in the Emergency Department with a diagnosis of Aspiration Pneumonia.

Staff Member #1 stated, "The physicians are the people who drive the discharge instructions. The nurse only reviews the information with the patient and/or family. The nurse should have rechecked the information especially when the spouse was questioning the information."