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Based on review of policies and procedures, medical staff bylaws, medical record, and staff interviews, it was determined that the provider failed to require that the medical staff was accountable to the governing authority by ensuring that physician orders were written for one of one patient (Pt # 1) related to dietary needs when this patient had a noted change in his/her medical condition. Failing to ensure staff were provided specific orders related to one to one supervision when the patient was eating posed a high potential risk to the health and safety needs of this patient, which resulted in a negative outcome for patient # 1.

Findings include:

Review of the policy titled Medical Record Content: "...Procedure...A. A medical record is maintained for every individual assessed or treated. The medical record must address the presence, accuracy, timeliness, legibility, and authentication of the following data and information...diagnostic and therapeutic orders...."

Review of the document Medical Staff Bylaws: "...Qualifications and Obligations of Membership or Clinical Privileges...General Obligations...each Applicant by applying for any category of membership or Clinical Privileges, obligates himself to continuously: ...Abide by these Bylaws, by the rules and regulations, and by all other applicable policies and procedures of hospital including, without limitation, adherence to any policies promulgated by the governing board...completion in a timely manner the medical and other required records for all patients he admits or in any way provides care in the Facility, in accordance with State law and hospital policy, including the requirement for completing and documenting medical histories and physical examinations...Provide continuous care for his patients and delegate the responsibility for diagnosis or care of patients only to those individuals that possess the requisite unrestricted Clinical Privileges to undertake that responsibility...Provide all his patients with care at such levels of professional quality and efficiency as may be established from time to time in the Rules and Regulations, or as may otherwise be established from recommendations made by the Medical Executive Committee and approved by the Governing Board in the manner provided herein...Prepare and complete, in a timely and adequate fashion, and in compliance with any applicable policies approved by the Governing Board, the medical and any other required records, including the face sheet, applicable to all patients he admits or in any way provides care for in Hospital...."

Provider # 1 Order dated 06/07/2018 revealed: "...change diet to pureed ADA, dysphagia...."

Provider #1 Progress Note dated 06/07/2018 revealed: "...ASSESSMENT AND PLAN...1. Dysphagia: Patient was on mechanical soft diet, but [he] is choking with it, as per [his] nurse report. We will change it to pureed diet. Dietician is aware...."

Provider #1 Progress Note dated 06/11/2018 revealed: "...ASSESSMENT AND PLAN...2. Dysphagia: [He] is on pureed diet and one-on-one feeding supervision...."

Provider #1 confirmed in an interview on 06/21/2018, that s/he failed to write the order for one-on-one supervision while Pt #1 was eating.

Employee #1 confirmed in an interview on 06/21/2018 that the facility does not have a policy that specifically addresses one-on-one feeding supervision.

Based on review of policies and procedures, documents, and medical record, it was determined that the facility failed to require that the registered nurses (RN's) ensured that all nursing staff delivering care to Patient # 1 were informed of this patients issue with difficulty swallowing, that the nursing care plan was current and that all staff followed the facility policy related to Dietary services. Failure of the nursing staff to follow their own policies and procedures, and ensure the nursing care plan for each patient was current posed the high potential risk that the needed treatments and interventions were not be carried out as ordered, and result in an adverse outcome for this patient.

Findings include:

Review of the policy titled Medical Record Content revealed: "...Procedure...A. A medical record is maintained for every individual assessed or treated. The medical record must address the presence, accuracy, timeliness, legibility, and authentication of the following data and information...all assessments and any revisions of the treatment plan...the patient's response to the care provided. When specific care goals are developed as part of the initial assessment process, progress or lack of progress towards goal achievement is documented...."

Review of the policy titled Dietary Services revealed: "...Staff will complete verification of meals/snacks and meal delivery as outlined ...."

Hospital Document #1 revealed that Patient # 1 had a choking incident on 06/06/2018, and staff performed the Heimlich maneuver. Pt # 1 did not lose consciousness.

Physician #1 order dated 06/07/2018 revealed: "...change diet to pureed American Dietetic Association (ADA), dysphagia...."

Pt # 1 medical record revealed updated care plans for skin integrity and fall risk following various incidents, but did not include any changes in care for difficulty swallowing following the 06/06/2018, choking incident.

Pt #1 medical record revealed Pt #1 was given crackers by a Behavioral Health Technician (BHT) on 06/16/2018, at which time the patient choked, subsequently expiring after being transported by Emergency Medical Services to an acute care hospital.

Employee # 1 confirmed during interview on 6/21/18, that Patient # 1's plan pf care did not include any changes to dietary needs to reflect the patient having difficulty with swallowing.