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Based on review of documentation and interview with the Risk Manager, no accounting of what patient #1 had on his meal tray at the time of a choking incident is noted in the record which was an important factor in determining the actual cause of patient #1's choking incident.

Patient #1 was admitted to the psychiatric hospital for 46 years for ongoing serious mental health concerns. Patient #1 had a history beginning in 2014 of discreet choking events. A Master Problem List revealed the addition on 6/2014 of "Dysphagia and aspiration." Choking events occurred approximately one year apart until 6/4/16 when patient #1 had a choking episode on mashed potatoes that resulted in an emergency department visit and subsequent antibiotics for aspiration pneumonia.

Patient #1 had an evaluation and numerous follow-ups by a Speech Language Pathologist (SLP). There was also a concern that patient #1's choking episodes could be related to seizure activity. Consequently, patient #1 was in part, on a puree diet with 100% nursing supervision for choke risk. In late April 2017, patient #1 had a choking event. Staff attempted Heimlich maneuver without success, and called a code blue and 911 as they continued to attempt resuscitation when patient #1 became unresponsive. Patient #1 was transported to the hospital by emergency medical technicians where he was determined to have suffered an anoxic brain injury.

A "Somatic Note" of 5/2/17 at 11 am revealed in part, "Pt brought to (hospital) after choking on his dinner. CPR started by staff at (psychiatric hospital) then taken over by EMS. During intubation large amounts of pieces of meat recovered from trachea ..." Since patient #1 was ordered a puree diet, pieces of meat should not have been able to be recovered from his trachea. Therefore it is apparent that the patient did not receive the diet as ordered. .

Interview with the Risk Manager on the day of survey regarding what foods were found on patient #1's tray revealed that the tray was not observed at the time of the incident, and that no staff could supply this information. Based on this, important information regarding the baseline safety of patient #1 at the time of the incident was not available, which negatively impacted the subsequent quality investigation.

Based on a review of 10 patient records and interview, it was revealed that the hospital failed to define nursing staff monitoring parameters for patients with a choking risk.

Review of patient records for patients #2, 4, 5, 6, and 7 who were determined to have a choking risk, revealed nursing observation for choking risk orders alternately as:

1. ...Puree diet ...100% staff supervision x 30 days ...Choke risk
2. Staff supervision while patient is eating ...Choke Risk x 30 days
4. Choke Risk precaution
5. Supervise at meal & snack time; ...Monitor for choking
6. Staff supervision with meals to prevent choking
7. "CHOKE RISK." Pt to have 100% nursing supervision while eating/PO intake

Interview with the Risk Manager on 7/11/17, the day of survey revealed that no hospital policy existed to define observation levels or parameters for patients determined to have a choking risk for both monitoring and choking precautions. Based on this, the hospital is unable to determine the level of nursing supervision and evaluation given to patients with choking risks.