HospitalInspections.org

Based on interview and document review, the critical access hospital (CAH) nursing staff failed to promptly assess and intervene for 1 of 1 swing bed patient (P6), who swallowed his lower partial denture and demonstrated symptoms of decreased oxygenation.

Findings include:

P6's face sheet identified he was admitted to the critical access hospital (CAH) swing bed 12/31/18 status post hip repair. P6 had upper and lower dentures.

P6's nursing notes (NN) dated 12/31/18, indicated P6 had full upper and lower dentures with 3 natural lower teeth. The notes did not indicate what condition P6's dentures were in, or how well they fit. A NN from 1/2/19, indicated staff were unable to determine P6's level of understanding and comprehension due to difficulty with communication. P6's NN also indicated the resident had a history of dementia and required a nectar thick diet related to swallowing and aspiration concerns. A progress note documented by the dietician on 1/2/19, indicated P6 had full upper and lower dentures, and was known to thrust the dentures in and out of his mouth.

The acute care nurse manager, registered nurse (RN)-A, was interviewed on 4/2/19 at 3:00 p.m. During the interview, RN-A verified P6 had been identified as having swallowing concerns at the time of admission to the critical access hospital (CAH).

The Electronic Medical Record (EMR) indicated P6's food and fluid intake for 1/3/19 at lunch was 100%; 1/4/19 breakfast was 100%, lunch was 75% and dinner was 40%; 1/5/19 breakfast was 25%, lunch was 50% and dinner was bites; 1/6/19 breakfast, lunch and supper were all documented as bites only; 1/7/19 breakfast indicated bites.

A chest x-ray report obtained 1/7/19 at 12:18 p.m. indicated P6 had a foreign body (dental bridge) in the upper area at the thoracic inlet.

The North Memorial Pre-Hospital Care Report, documented by an Advance Trained Paramedic with the ambulance, indicated P6 was transferred via ground ambulance non-emergently (no lights or sirens), for higher level of care to a receiving hospital for neuro-altered mental status, and GI (gastrointestinal)-esophageal obstruction. The notes included: "Treatments:...oriented-person, confused; ...breath sounds-normal-left, breath sounds-normal-right...Reassessment: Routine transport to Rice (name of hospital). Pt (patient) rested comfortably. NS (normal saline) running at 150/hr continued during trip. No changes during trip." Oxygen saturation (O2) levels documented during the transport indicated P6's oxygen levels were 69-79% over the half hour transfer, but the patient's respirations remained consistent at 22 and there were no notes indicating the patient suffered from shortness of breath.

The Carris Health Rice Memorial Hospital procedure notes for P6, documented 1/7/19 at 5:52 p.m., included: "...he had his lower denture come loose and get lodged in the hypopharynx and verified by x-ray. He was transferred to Willmar...Direct laryngoscopy was then performed. The denture was visualized in the hypopharynx just above the arytenoids. This was grasped with the McGills forceps and removed. The tooth root from tooth #8 was extremely loose so this was moved to prevent an additional foreign body."

A video swallow study report dated 1/9/19, was reviewed and included: "Findings: Video swallow performed with speech therapy. The patient was given barium of thin liquid consistency. The patient demonstrated little if any volitional swallow, with the contrast bolus simply spilling over the face of the tongue.."

During interview with the hospital's director of nursing (DON) on 4/3/19 at 10:45 a.m., the DON verified nursing staff should have called a rapid response when P6's respirations increased, O2 saturations decreased, and it was determined P6 may have aspirated. At 10:56 a.m., Registered Nurse (RN)-A and the DON reiterated protocol changes implemented after P6's aspiration event on 1/7/19. They stated the nurses were expected to round once per shift, performing an assessment and evaluation through gathering data including vital signs, level of consciousness, etc. If a patient was determined to have a change of condition, staff would be expected to perform these assessments as often as needed. Again, the DON verified the nursing staff had not followed the CAH's rapid response policy to call for assitance immediately when they noticed changes to P6's condition, decreased cognition and decreased intake. The DON further stated following the incident, they had initiated an investigation. The DON stated they had focused on denture aspiration, versus lack of documentation, or the delay in obtaining the X-ray order. The DON and RN-A agreed policies should have been followed.

RN-B was interviewed on 4/3/19 at 11:15 a.m., and stated she had been called into P6's room when the nurse aide was attempting to feed P6 his breakfast on 1/7/19. RN-B stated, "Although swing bed patients are not seen by their MD's (medical doctor) every day, MD-A was completing weekly rounds and saw [P6] prior to breakfast that day." RN-B stated increased monitoring would only occur based on the condition of the resident, and might not be routine for potential aspiration. RN-B stated P6's oxygen saturations (SpO2) were being monitored by a machine in his room that was set to alarm for SpO2 lower than 90%. She was unaware if P6's SpO2 had dropped because the nursing staff hadn't recorded these details. RN-B verified she had made no documentation in the EMR to verify she had checked on P6 or conducted monitoring when P6 had the suspected aspiration. RN-B also confirmed she had not assessed P6 for appropriate fit for his dentures, but had identified a potential aspiration risk on 1/7/19. RN-B stated the respiratory therapist (RT)-C had been summoned to evaluate and suction P6, and that she had contacted MD-A following RT-C's assessment to alert MD-A of the potential aspiration. Furhter, RN-B verified MD-A had given a verbal order requesting a routine X-Ray order which RN-B had not immediately entered into the EMR, nor had RN-B immediately notified the X-Ray department to have them complete. RN-B verified she had input the order over 2 hrs later, at 12:18 p.m. which caused a delay in determining P6 had aspirated his denture, and had delayed potential treatment. RN-B said she had contacted MD-A at 12:22 p.m. on 1/7/19 as soon as she'd been informed of the X-Ray results. RN-B acknowleged she should have called a Rapid Response per hospital protocol between 9:30 a.m and 10:00 a.m. instead of collaborating only with the RT. RN-B stated if the Rapid Response had been initiated, the emergency room doctor would have immediately assessed P6, therefore not delaying diagnosis and treatment. In addition, RN-B acknowledged once the denture had been identified in P6's throat, she had not provided continuous oversight to prevent any further complication.

During interview with MD-A on 4/3/19 at 12:55 p.m., MD-A verified he'd seen P6 on the morning of 1/7/19, while doing rounds at approximately 8:00 a.m. MD-A stated at that time, P6 was waxing and waning, but stated P6 had shown no signs of respiratory distress. When asked about the nurse's response to the resident's condition, MD-A stated had the nurse instituted their rapid response, the emergency room physician would have conducted an immediate assessment. MD-A also confirmed based on the information provided from RN-B, he'd given RN-B a verbal order for a routine X-ray to be done.

RN-C was interviewed on 4/3/19 at 3:15 p.m. RN-C identified she had also worked on 1/7/19 and helped provide care to P6. RN-C stated she remembered P6 had experienced coughing episodes beginning on 1/5/19. RN-C also stated she'd seen a nursing assistant put P6's dentures in on 1/6/19, but did not observe whether the NA had removed them later that evening. When RN-C was asked about the events surrounding P6's aspiration, RN-C stated she had not felt a rapid response was needed because RT-C's office was close (around the corner from P6's room) and he'd come to assess P6 right away after being called by RN-B.

RT-C was interviewed on 4/3/19 at 4:05 p.m. RT-C stated he was called around 9:30 a.m. on 1/7/19 by RN-B to P6's room because P6 was experiencing increased shortness of breath (SOB) and decreased oxygen levels. RT-C stated P6 was in respiratory distress, was gurgling, and had a coarse upper airway sounds. RT-C performed deep suctioning without any resistance in P6's airway. RT-C stated he had recommended an X-Ray to determine potential aspiration because P6 had thick secretions, and he had gotten some apple sauce back when he suctioned P6. RT-C further explained he had not been providing any routine cares for P6 upon admission because he had been clinically stable at his 12/31/18 admission. RT-C stated even though P6 had a history of chronic obstructive pulmonary disease (COPD), he had not required any routine oxygen prior to the incident.

During a follow up interview with the DON on 4/3/19 at 4:40 p.m., the DON stated RN-B should have stayed with P6 when she had suspected he had aspirated to continuously monitor P6. Further, the DON stated RN-B should have conducted additional assessment and performed vitals every (q) 15 minutes x 4, q 1/2 hr x 2 and so on until P6 was back to baseline.

During a follow up interview with MD-A on 4/4/19 at 9:15 a.m., MD-A acknowledged he had not been aware RN-B had failed to implement the X-ray order for more than 2 hours after he'd given the order. In addition, MD-A stated he was unaware NA-A had reported she'd attempted to feed P6 his noon meal. MD-A stated nursing staff should have placed P6 on a 1:1 staff to patient ratio when they suspected aspiration after the RT's assessment, and should have been immediately identified P6 as NPO per nursing order. MD-A stated once he'd received the X-ray results, he'd immediately come back to the nursing floor to assess P6. MD-A described P6 at that time as coughing, in respiratory distress and requiring surgical intervention to remove the partial denture, as he was unable to see the denture in P6's throat upon his visual examination. As a result, MD-A made the determination to transfer P6 to a higher level of care for surgical intervention.

When interviewed on 4/4/19 at 9:55 a.m., NA-A verified she had worked the weekend of 1/5/19 and 1/6/19. NA-A said she remembered P6 as only having upper dentures and not lowers because P6 would flick his dentures in and out with his tongue and independently remove them. NA-A stated she would assist P6 to remove the denture at bedtime if he hadn't already removed it. NA-A said P6 had eaten bites of applesauce the morning of 1/7/19, given with his medication. NA-A stated she'd tried to feed P6 lunch around 12 noon that day because she had not been informed by RN-B not to feed him. She stated when she'd attempted to feed P6, he'd started coughing and was unable to eat.

Review of the facility's 1/8-1/10/19 post incident investigation notes, identified although they had conducted analysis and determined the need for additional assessment to be built into the electronic medical record (EMR), and had taken steps to correct this concern, they failed to identify the lack of appropriate action by RN-B in delayed entry of the X-ray order, and failure to follow the facility's Rapid Response policy designed to ensure immediate care was provided in urgent or emergent situations.

Review of the facility's November 2017, Evidence Based Practice policy, identified steps in the process included clearly identifying issues based on an accurate assessment and current professional knowledge and practice.

Review of the facility's June 2018, Rapid Response Team System policy, identified its goal was to provide early and rapid intervention. Any employee, patient, family, physician, specialist could activate the system in response to acute deterioration of health. The policy indicated provisions for calling a rapid response included patients with sudden respiratory and neurological changes, new SpO2 less than 90%, acute mental status changes, and a respiratory rate over 28. The protocol indicated an ER physician and 1 to 2 members of each clinical team were to respond immediately. The house supervisor (HS) would then speak with the primary nurse and get the situation, background, and assessment of the patient, and determine if the attending or primary physician needed to be called. The HS was to assist nursing staff with further assessment of the patient, and recommend treatment as warranted. Staff were to initiate appropriate treatment to stabilize the patient. Finally, the protocol indicated an RN was to stay with the patient until the patient was stable or transferred.