HospitalInspections.org

Based on document review, medical record review and interview, the facility did not ensure a swallow screen was conducted and aspiration precautions were implemented in accordance with facility policy for Patient #2 who presented with a history of difficulty swallowing, on a modified diet and rule out for cerebrovascular accident (CVA).

Findings include:

Review of Emergency Department (ED) physician note dated 08/22/2020 at 10:45 AM, ED revealed Patient #2 presented from an individual residential alternative (IRA) group home and has a history of dysphagia, brought in for difficulty ambulating. Based on clinical assessment, diagnosis included CVA and the patient was admitted for further work-up. At 10:47 AM an order for nothing by mouth and bed side swallow screen was entered.

Review of policy titled "Swallow Screening: Provision of Care-Nursing", last revised 12/2019 revealed dysphagia screening is a form of bedside testing to screen for swallowing difficulties that can be performed by healthcare professionals, including registered nurses, who are not speech language pathologists (SLP). Swallow screen patient exclusion criteria includes modified diet consistency. If any exclusion criteria exist, do not continue. Document results in medical record and if a patient has any exclusion criteria, such as a modified diet, maintain nothing by mouth status, repeat screen in 24 hours and implement aspiration precautions.

Review of nursing guidelines utilized by the facility (Clinical Nursing Skills and Techniques by Perry and Potter 2014) revealed when a patient is at risk for dysphagia and aspiration, referral for a more comprehensive examination is necessary. When risk factors are detected, the SLP is consulted for dysphagia screening. Aspiration precautions while feeding a patient include an upright position, monitoring of swallowing and observation for any respiratory difficulty.

Review of ED Nursing Assessment dated 08//22/2020 at 01:17 PM revealed Patient #2 was on a modified diet consistency and the bed side swallow screen was not completed due to the diet exclusion.

Review of policy titled "Swallow Screen: Rehabilitation Services", last reviewed 04/2021 revealed individuals who fail the screening are referred for a full swallow function assessment by a SLP and/or other medical services if appropriate.

Review of admission orders for Patient #2 dated 8/23/2020 at 08:30 AM revealed an order for a regular diet with thickened liquids and assistance with feeding. There is no documentation to indicate the swallowing screen was repeated per facility policy or that the patient was referred to the SLP for a full swallow assessment.

Interview with Staff (AA), Nursing Assistant on 3/31/2021 at 10:00 AM revealed on the afternoon of 8/29/2020 Patient #2's food tray was set up and the patient was left to feed herself. Information relayed to Staff (AA) from the previous shift indicated Patient #2 did not require assistance with feeding beyond setting up the food tray.

Review of nursing notes dated 8/29/2020 at 04:42 PM revealed Patient #2 was found unresponsive. A rapid response was called and during the resuscitation, vegetable matter was found in the patient's throat.