HospitalInspections.org

Based on medical record (MR) review, document review and interview, 1) in 1 of 5 MRs reviewed, the hospital did not ensure the recommendations from a swallow evaluation, completed by the speech language pathologist (SLP), were conveyed to the patient's provider prior to transfer to a skilled nursing facility (SNF). Also, 2) the hospital does not have a process to ensure a provider is notified when a change in diet has been recommended by a SLP. This has led to staff verbalizing inconsistent understanding of steps necessary to ensure recommendations from a swallow evaluation are reported to the provider. This lack of a process could lead to adverse events.

Findings regarding (1) above:

-- MR review admission #1 from 9/14/19 - 9/16/19. Patient #1 (96-year-old male) was admitted on 9/14/19 at 12:46 pm with a broken leg. Patient #1 had dementia and was oriented to himself and partially oriented to place. The hospitalist ordered a mechanical soft diet on admission.

On 9/15/19 at 5:00 pm nursing documented the patient was being assisted with the mechanical soft diet. While drinking apple juice, the patient coughed and choked. After a minute the patient was able to speak. He was made NPO (nothing by mouth) until a swallow evaluation was completed.

On 9/16/19 at 10:48 am a swallow evaluation was completed. The recommendations included nectar thickened liquids, diced solids and meds crushed in puree. The SLP recommendations were verbalized to the registered nurse (RN) caring for the patient.

The order for discharge to the SNF was written on 9/16/19 at 10:50 am and indicated the diet was regular mechanical soft. Patient #1 was discharged to the SNF at 1:55 pm.

The MR lacked documented evidence that the provider was notified of swallow evaluation results and SLP recommendations.

-- MR review admission #2 from 9/17/19 - 9/18/19. Patient #1 was readmitted to the hospital 9/17/19 at 12:34 am with a diagnosis of aspiration pneumonia, respiratory failure and congestive heart failure. While eating at the SNF he choked on food and required the Heimlich maneuver (abdominal thrust to clear foreign bodies from the airway) to clear his airway. He was noted to be hypoxemic (an abnormally low level of oxygen in the blood) and was transported to the hospital for evaluation. Documentation by the SLP at 2:08 pm indicated Patient #1 had a swallow evaluation done on 9/16/19 which recommended his diet be downgraded to diced foods and nectar-thick liquids, however, he was discharged on 9/16/19 on mechanical soft diet with thin liquids.

Findings regarding (2) above:

-- Per interview of Staff A, SLP, on 10/24/19 at 2:37 pm, the process for providing results and recommendations of swallow evaluation is to give report in person to the charge nurse, the primary nurse or the provider and document in the MR. Staff B does not enter the order in the MR, the provider must enter the order.

-- Per interview of Staff B, RN, on 10/25/19 at 9:58 am, if a patient has a swallow evaluation the SLP reviews the results with the provider, who clarifies any diet order changes. The SLP must communicate with the provider.

-- During interview of Staff C, RN, on 10/24/19 at 2:15 pm, The SLP notifies "everybody" of the results of a swallow evaluation. The SLP will give report to the primary nurse or the charge nurse. The providers write the diet instructions and are responsible for changing the discharge instructions as needed.

-- During interview of Staff D, RN, on 10/24/19 at 2:47 pm, the SLP personally tells staff the results of the swallow evaluation, either the primary nurse or the charge nurse, usually the charge nurse. The SLP and charge nurse decide who is going to notify the provider of the results of the study and the diet recommendations.

-- During interview of Staff E, RN, on 10/25/19 at 11:45 am, the primary nurse is responsible to notify the charge nurse if there is a swallow evaluation done indicating a change. The order could be entered and then the provider notified. Staff E thinks the diet order is automatically pulled over for discharge instructions, but he/she is not sure.

The hospital does not have a consistent process to ensure providers are made aware of the diet recommendations by the SLP after a swallow evaluation has been completed.

-- During interview of Staff F, Director Patient Safety and Quality, on 10/25/19 at 11:10 am, he/she acknowledged the above findings.

Based on document review, medical record (MR) review and interview, 1 of 3 MRs (Patient #2) reviewed of patients who required skilled nursing facility (SNF) placement, lacked documentation that the patient and/or their representative were provided a list of Medicare-participating SNFs. This could impact a patients freedom of choice in selecting a facility for placement.

Finding include:

-- Review of the hospital's policy and procedure (P&P) titled "Patient's Choice for Post - Hospital Services, Requirement," last revised 8/2019, indicated the case manager (CM) or social worker (SW) should present the UREV-14C (Inpatient Skilled Nursing, Rehabilitation and Long-term Care Services Referral Options Checklist) to patients for whom post acute-care services are indicated. The CM or SW will obtain a signature and date of the patient or individual acting on the patient's behalf on the form UREV-14C.

-- Review of Patient #2's MR indicated, on 10/21/19 at 11:30 am, the CM documented, options for short term rehabilitation were discussed with the son referral sent. The UREV-14C form was not in the MR. This finding was confirmed by Staff G, Quality Improvement Coordinator at the time of MR review.