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DEACONESS HOSPITAL INC
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on document review and interview, the facility failed to meet the dietary needs of 1 of 10 patients (patient #1) per medical record (MR) review.
Findings included:
1. Facility Procedure in the Patient Care Technician (PCT) book titled: Dysphagia Diet, (no number or date) which indicated that when patients need direct supervision ... one to one assist with meals, small bites/sips (1/2 spoon bite size for food/liquid). Upright as possible for all oral intake. Remain upright for 20-30 minutes after meals...
2. Review of patient #1's MR Clinical Swallow Evaluation, dated 10/13/2018, at 1359 hours, authored by staff member #4, Speech and Language Pathologist, indicated: Aspiration Risk: Severe. Diet recommendation: Dysphagia Level 2. Compensatory Swallowing Strategies: Upright as possible for all oral intake. Remain upright for 20-30 minutes after meals, one to one assist with meals, small bites/sips (1/2 spoon bite size for food/liquid). Recommendations: Speech Therapy recommends patient to remain on the "safest oral diet of Dysphagia II - puree and honey thick liquids based on the results of the swallow evaluation.
3. Review of patient #1's MR Pulmonary and Critical Care Consultation Note, dated 10/15/2018, at 0059 hours, authored by QMP #3, MD, Pulmonary, indicated: Patient was left unsupervised (with diet). Concerned that they may have aspirated with worsening O2 saturation requirements, resulting in they being on a non rebreather mask, satting 82%. Impression: Acute hypoxic respiratory failure, aspiration with mucous plugging.
4. Review of patient #1's MR Discharge Summary, dated 10/17/2018, at 1604 hours, authored by QMP #2, MD, Internal Medicine, indicated: Hospital course: After transferring to the ICU, patient was placed on ventilation support. Palliative care was consulted, patient was made do not resuscitate and placed on comfort care with plan for placement at hospice, but patient was found unresponsive, was declared deceased at 1320 hours, secondary to aspiration pneumonia with acute hypoxic respiratory failure due to dysphagia.