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Based on document review and interview, it was determined, for 1 of 1 (Pt. #1) patient death reviewed, the Hospital failed to conduct a thorough investigation of an unanticipated patient death, implement corrective measures and track that corrective measures were sustained. The cumulative effect of these systemic practices resulted in the Hospital's inability to ensure safe patient care. The Condition of Quality Assessment and Performance Improvement (42 CFR 482.21) was not met.

Findings include:

1. The Hospital failed to ensure adverse patient outcomes were fully investigated and corrective actions were implemented and monitored for effectiveness, (A-0286).

Based on document review and interview, it was determined for 1 of 1 (Pt. #1) patient death reviewed, the Hospital failed to conduct a thorough investigation of an unanticipated patient death, implement preventative actions, and track that improvements were sustained.

Findings include:


1. On 5/29/14 at 9:45 AM, the Hospital policy titled, "Quality Improvement Plan" effective 9/04 was reviewed. The policy required the Quality Improvement Council will evaluate corrective actions and confirm the actions resulted in improvements. The policy required any unanticipated death would be a sentinel event and require a root cause analysis.

2. On 5/29/14 at 9:50 AM, the Hospital policy titled, "Sentinel Event Review and Reporting" effective 8/2005 was reviewed. The policy required improvement activities or risk reduction strategies to be monitored for effectiveness by the Patient Safety and Quality Improvement Committee: ... " Policy: Adverse Sentinel Event: The Sentinel Event Policy applies to events that meet the following criteria: 1). The event has resulted in an unanticipated death ...Root Cause Analysis (RCA) including Action Plan: ... b). The product of the root cause analysis is an action plan that identifies the strategies that the organization intends to implement to reduce the risk of similar events occurring in the future. The plan should address responsibility for implementation, oversight, pilot testing as appropriate, time lines, and strategies for measuring the effectiveness of the actions .... "

3. On 5/27/14 at 11:00 AM, Pt #1's clinical record was reviewed. Pt. #1 is a 71 year old female with diagnoses of symptomatic cholelithiasis (gallbladder issues), dysphasia (difficulty swallowing), and mental retardation, who was admitted on 12/30/13 for same day surgery to remove her gallbladder via a scope (cholecystectomy laparoscopic). Pt. #1 was subsequently admitted as a inpatient due to more invasive surgical intervention. Pt # 1 was a resident of a group home and had a colostomy, gastric feeding tube, and was NPO for undetermined an number of years, prior to hospital admission. Pt. #1 died on 1/2/14 after acquiring aspiration pneumonia and sepsis (generalized infection of the body), secondary to eating food.

4. During an interview on 5/28/14 at 2:20 PM, E #1 (Director of Quality) stated a root cause analysis was conducted after Pt #1's unanticipated death. E #1 stated education on processing orders was provided to the food and nutrition staff, nurses, nurse aids and unit secretaries, as identified in the root cause analysis. E #1 stated that the hospital could not provide documentation of the root cause analysis or adverse event logs because it was part of the patient safety and work product. E #1 stated there had been no monitoring of the effectiveness of the education either at a departmental level or at the Quality Improvement Committee level. E #1 stated "we really didn't follow up like we should have."

5. On 5/29/14 at 2:00 PM, the Quality Improvement Committee meeting minutes dated January 2014 to May 2014 were reviewed. A sentinel event was mentioned in the January 2014 minutes, but did not include a patient name or specifics. The meeting minutes lacked documentation of Pt. #1's adverse event, corrective actions implemented or monitoring of the corrective actions. Requests for root cause analysis and adverse event logs were denied. Therefore unable to determine that the incident was fully investigated.







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Based on document review and interview, it was determined for 7 of 9 (Pt. #1, #2, #4, #5, #6, #7, and #8) clinical records reviewed of developmentally disabled patients, the nurses failed to ensure a complete diet order was obtained; and for 8 of 10 (Pt. #1, 2, 3, 4, 5, 6, 7 and 8) clinical records reviewed, the Hospital failed to ensure medications were administered and ordered per policy. The cumulative effects of these systemic practices resulted in the Hospital's inability to ensure nurses provided safe patient care. The Condition of Nursing Services (42 CFR 482.23) was not met.

Findings include:

1. The Hospital failed to ensure diet orders were obtained, (A-0395).

2. The Hospital failed to ensure medications were ordered and administered per policy, (A-0405).


The Immediate Jeopardy began on 12/31/13, (identified on 5/30/14) when the Hospital failed to ensure that nurses obtained complete diet orders for all patients with g-tubes and dysphasia (difficulty swallowing), to include feeding solution type, volume, and oral intake or NPO (nothing by mouth) status.

Pt. #1 is a 71 year old female with diagnoses of symptomatic cholelithiasis (gallbladder issues), dysphasia (difficulty swallowing), and mental retardation who was admitted on 12/30/13 for same day surgery to remove her gallbladder via a scope (cholecystectomy laparoscopic). Pt. #1 subsequently was admitted as a inpatient due to more invasive surgical intervention. Pt # 1 was a resident of a group home and had a colostomy, gastric feeding tube, and was NPO for an undetermined number of years, prior to hospital admission. Pt. #1 died on 1/2/14 after acquiring aspiration pneumonia and sepsis (generalized infection of the body), secondary to eating food on 12/31/13. The clinical record included a physician's order dated 12/30/13, "Resume Pt. NH TF (tube feeding) @ (at) 15 cc/hr..." The clinical record lacked documentation of a complete diet order by a physician, to include the feeding solution type as well as any oral diet or NPO status.

An Immediate Jeopardy (IJ) and serious threat to patients' safety and wellbeing was created from the cumulative effects of these systemic practices. The Chief Executive Officer (E #15) for the Hospital was notified of the Immediate Jeopardy on 5/30/14 at 2:00 PM. The Immediate Jeopardy was not removed by the exit date because the Hospital failed to conduct a thorough investigation of an unanticipated patient death, implement corrective measures and track that corrective measures were sustained.

Based on document review and interview, it was determined for 7 of 9 (Pt. #1, #2, #4, #5, #6, #7, and #8) clinical records reviewed of developmentally disabled patients, the nurses failed to ensure a diet order was obtained.

Findings include:

1. On 5/29/14 at 12:00 PM, the Hospital policy titled, "Diet Orders" effective on 11/09, was reviewed. The policy required the physician writes a diet order in the medical record; writes a diet order for "NPO" when a patient is not allowed oral intake; writes new diet orders to resume oral intake for patients who have been NPO; writes orders for tube feedings and any oral diet to accompany the tube feeding. The policy required nurses to enter the diet into the Hospital's information system and notify Food/Nutrition of any changes in diet orders.

2. On 5/27/14 at 11:00 AM, Pt. #1's clinical record was reviewed. Pt. #1 is a 71 year old female with diagnoses of symptomatic cholelithiasis (gallbladder issues), dysphasia (difficulty swallowing), and mental retardation who was admitted on 12/30/13 for same day surgery to remove her gallbladder via a scope (cholecystectomy laparoscopic). Pt. #1 subsequently was admitted as a inpatient due to more invasive surgical intervention. Pt # 1 was a resident of a group home and had a colostomy, gastric feeding tube, and was NPO for an undetermined number of years, prior to hospital admission. Pt. #1 died on 1/2/14 after acquiring aspiration pneumonia and sepsis (generalized infection of the body), secondary to eating food. The clinical record included a physician's order dated 12/30/13, "Resume Pt. NH TF (tube feeding) @ (at) 15 cc/hr..." The clinical record lacked documentation of a complete diet order by a physician, to include the feeding solution type as well as any oral diet or NPO status.

The nursing staff entered the following diet and NPO orders into the computer: E5 (unit secretary) entered a liquid diet order on 12/30/13 at 3:30 PM, and an order for " tube feeding " entered on 12/30/13 at 3:34 PM by E5. E5 did not include the type or amount of feeding solution. An order for NPO was entered on 12/31/13 at 7:59 AM by E4 (unit RN). There was no physician's order for NPO in Pt. #1's hospital clinical record. The clinical record lacked documentation that the physician was contacted concerning these orders, prior to the orders being entered into the computer by the nursing staff.

3. On 5/27/14 at 2:45 PM, Pt. #2's clinical record was reviewed. Pt. #2 was a 72 year old developmentally disabled male who resided in a group home, admitted on 5/26/14, with a diagnosis of pneumonia and had a g-tube for dysphagia . A physician's order dated 5/26/14 noted, "resume tube feedings at 1/2 the volume given at group home...Diet: follow g-tube feeding..." The clinical record lacked documentation of a complete diet order to include feeding solution type and volume, as well as any oral diet or NPO status.

4. On 5/27/14 at 4:00 PM, Pt. #4's clinical record was reviewed. Pt. #4 was a 74 year old developmentally disabled female who resided in a group home, admitted on 5/22/14, with a diagnosis of pneumonia and had a g-tube for dysphagia. The clinical record lacked documentation of a diet order.

5. On 5/28/14 at 9:00 AM, Pt. #5's clinical record was reviewed. Pt. #5 was a 62 year old developmentally disabled female, admitted on 5/28/14, with a diagnosis of pneumonia. A physician's undated order noted, "...Diet: follow NH diet order.." The clinical record lacked documentation of a complete diet order to include feeding solution type and volume, as well as any oral diet or NPO status.

6. On 5/28/14 at 10:00 AM, Pt. #6's clinical record was reviewed. Pt. #6 was a 56 year old developmentally disabled female who resided in a group home, admitted on 4/24/14, with a diagnosis of seizure disorder/hx of aspiration and had a g-tube for dysphagia. The clinical record lacked documentation of a complete diet order to include feeding solution type and volume, as well as any oral diet or NPO status.


7. On 5/27/14 at 2:30 PM, Pt. #7's clinical record was reviewed. Pt. #7 was an 83 year old developmentally disabled male who resided in a group home, admitted on 5/21/14, with a diagnosis of food/vomit pneumonitis and had a g-tube for dysphagia. A physician's order dated 5/26/14 noted, "resume tube feedings at 1/2 the volume given at group home...Diet: follow G-tube feeding..." The clinical record lacked documentation of a complete diet order to include feeding solution type and volume, as well as any oral diet or NPO status.


8. On 5/28/14 at 3:00 PM, Pt. #8's clinical record was reviewed. Pt. #8 was a 49 year old developmentally disabled male who resided in a group home, admitted on 5/6/14, with a diagnosis of pneumonia and had a g-tube for dysphagia. A physician's order dated 5/12/14 stated "resume previous group home feedings." The clinical record lacked documentation of a complete diet order to include feeding solution type and volume, as well as any oral diet or NPO status.

9. During an interview on 5/28/14 at 9:00 AM, E #13 (Charge Nurse) stated "I assume if a patient has tube feedings the patient is NPO... some patients with tube feedings eat...I'm not sure there is a place on the white board to write a diet...we would only write the diet on the white board if the patient was alert and oriented enough to understand...if a doctor writes to resume home feedings I either look at the nursing home transfer sheet or call the nursing home to see what diet they were on but I don't write that as an order..."

10. During an interview on 5/28/14 at 2:20 PM, E #7 (staff nurse) stated "I guess we assume if there is no diet order the patient is NPO and that's what is put on the Kardex and white board in the patients room...the Kardex is used for bedside report and that is when the white board is updated. The Kardex is frequently wrong because we forget to add and remove things. I don't think we consistently use the white board and the diet could be missed because it doesn't get changed...I could see if the diet wasn't correct on the board a tray could be passed."

11. During an interview on 5/27/14 at 2:30 PM, E #10 (Interim Director of Medical/Surgical Unit) stated it had been identified previously that diet orders were not being written and education had been given to the nurses regarding obtaining a diet order on 2/21/14. E #10 stated compliance had not been monitored after the education.

12. During an interview on 5/28/14 at 3:15 PM, E #1 (Director of Quality) and E #11 (Chief Nursing Officer) confirmed there was no diet order for Pt. #2, #4, #5, #6, #7, and #8 and there should have been.

Based on document review and interview, it was determined, for 8 of 10 (Pt #1, 2, 3, 4, 5, 6, 7 and 8) clinical records reviewed, the Hospital failed to ensure medications were administered and ordered per policy.

Findings include:

1. Hospital policy titled, "Orders: Drugs", dated 1/08 was reviewed on 5/29/14 at 9:00 AM. The policy required medication orders to include the drug name, strength and route.

2. Hospital policy titled, "Medication Administration" effective 11/05 was reviewed on 5/30/14 at 9:50 AM. The policy required "...medications to be administered safely and accurately utilizing the 5 rights of medication administration: The Right Medication. The Right Patient. The Right Dosage. The Right Time. The Right Route... Notify clinician if inconsistencies with route are identified for clarification."

3. Hospital policy titled, "Medication Reconciliation" effective 7/1/06 was reviewed on 5/30/14 at 12:00 PM. The policy required, "Patient medication information shall be documented on the Medication Reconciliation Admission order form. These forms serve as an approved physician's order requiring all components of an order...All drugs, dosages, routes and frequencies shall be included..."

4. On 5/27/14 at 11:00 AM, Pt #1's clinical record was reviewed. Pt #1 was a 71 year old developmentally disabled female who resided in a group home, admitted on 12/30/13, with a diagnosis of cholelithiasis, dysphagia (difficulty swallowing) and a g-tube (gastric tube). The medication reconciliation list dated 12/30/14 stated artificial tears eye solution was to be administered per g-tube. There was no documentation the nurse clarified the order/correct route with the physician. The medication profile report dated 1/1/14 noted two medications were administered by mouth.

5. On 5/27/14 at 2:45 PM, Pt. #2's clinical record was reviewed. Pt. #2 was a 72 year old developmentally disabled male who resided in a group home, admitted on 5/26/14, with diagnoses of pneumonia and dysphagia and had a g-tube. The medication reconciliation list dated 5/26/14 ordered four medications without an administration route and one medication without a dose. There was no documentation the nurse clarified the order route and dose) with the physician. The medication profile report dated 5/27/14 stated thirteen medications were administered by mouth.

6. On 5/27/14 at 4:00 PM, Pt. #3's clinical record was reviewed. Pt. #3 was an 85 year old developmentally disabled female who resided in a group home, admitted on 5/26/14, with a diagnosis of food/vomit pneumonitis. The medication reconciliation list dated 5/26/14 ordered one medication without an administration route. There was no documentation the nurse clarified the route with the physician.

7. On 5/27/14 at 4:00 PM, Pt. #4's clinical record was reviewed. Pt. #4 was a 74 year old developmentally disabled female who resided in a group home, admitted on 5/22/14, with diagnoses of pneumonia and dysphagia and had a g-tube. The medication reconciliation list dated 5/22/14 ordered eight medications without an administration route. The clinical record lacked documentation the nurse clarified the route with the physician. The medication profile report dated 5/23/14 noted three medications were administered although the clinical record lacked documentation of the route the medications were administered.

8. On 5/28/14 at 2:00 PM, Pt. #5's clinical record was reviewed. Pt. #5 was a 62 year old developmentally disabled female who resided in a group home, admitted on 5/28/14, with a diagnosis of pneumonia. The medication reconciliation list dated 5/28/14, included an order one medication without a dose. The clinical record lacked documentation the nurse clarified the dose with the physician.

9. On 5/28/14 at 10:00 AM, Pt. #6's clinical record was reviewed. Pt. #6 was a 56 year old developmentally disabled female who resided in a group home, admitted on 4/24/14, with a diagnosis of seizure disorder, hx of aspiration and had a g-tube. The medication profile report dated 4/30/14 noted two medications were administered by mouth.

10. On 5/27/14 at 2:30 PM, Pt. #7's clinical record was reviewed. Pt. #7 was an 83 year old developmentally disabled male who resided in a group home, admitted on 5/21/14, with a diagnosis of food/vomit pneumonitis. The medication reconciliation list dated 5/21/14 ordered three medications without a route. The clinical record lacked documentation the nurse clarified the route with the physician.

11. On 5/28/14 at 3:00 PM, Pt. #8's clinical record was reviewed. Pt. #8 was a 49 year old developmentally disabled male who resided in a group home, admitted on 5/6/14, with a diagnoses of pneumonia and dysphagia and had a g-tube. The medication reconciliation list dated 5/21/14 ordered four medications without a route and one medication without a dose. The clinical record lacked documentation the nurse clarified the route or dose with the physician. The medication profile report dated 5/12/14 stated five medications were administered by mouth.

12. On 5/28/14 at 11:00 AM, E #10 stated "we just crush them (medications). We know when a patient is NPO to give them through the G-tube...we don't always clarify the order because we know what it means but I see it now that you point it out that we should clarify it."

13. On 5/28/14 at 11:15 AM, E #12 (Director of Pharmacy) stated "I admit we get use to our providers and don't clarify some orders..." E #12 demonstrated how the medication reconciliation is used to enter medications into the software which produces the medication profile report used by the nurses for drug administration. E #12 stated and demonstrated when the medication is entered, routes and dosages are defaulted to the most commonly used.

14. On 5/28/14 at 2:20 PM, E #7 (staff nurse) stated "sometimes pharmacy will send the med recs (medication reconciliation list) back to the nurse and ask for clarification but I assume they have done it if I get a MAR (medication administration record).

15. On 5/28/14 at 3:15 PM, E #1 and E #11 confirmed Pt #1, 2, 3, 4, 5, 6, 7 and 8's medication reconciliation were incomplete and should have been clarified and the medication profiles indicated the medications were administered as stated above.