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Based on observations, documents, medical records review and staff interview, it was determined the Governing Body failed to ensure the hospital developed policies, procedures and training for Percutaneous Endoscopic Gastrostomy (PEG) tube (a tube placed through the abdomen directly into the stomach for feeding) and monitoring after feeding; policies, procedures and training of staff for patients listed as an aspiration risk (breathing in food or fluids when you swallow, vomit, or experience heartburn); policies, procedures and training of staff for the use of an Enclosure Bed (a bed that may be used for patients who are at high risk for falls; are confused, impulsive, restless, or agitated; are unable to ask for assistance or respond to redirection; or who climb out of bed when it's unsafe), the hospital failed to provide nurse staffing sufficient to meet patient needs and provide safe care for one of ten patient records reviewed (Patient 1) and failed to ensure the nursing staff evaluated the care of one of ten patients reviewed (Patient 1) on an ongoing basis in accordance with accepted standards of nursing practice and hospital policy.

The cumulative effects of these deficient practices have the potential to affect all patients treated at the hospital and could lead to a worsening of conditions or death.


Findings Include:


Document review of the hospital's "Operating Agreement" dated 01/01/27, showed in section 5.2 that, "Authority of the Board of Managers. Except as specifically reserved to the Members in this Agreement under the Act, the Board of Managers has all power and authority to manage and direct the management of the business and affairs of the company, both ordinary and extraordinary".

Document review of the hospital's, "Medical Staff Bylaws" dated 04/13/19, showed in Article X. Committees, 2. Medical Staff Executive Committee, b) Duties. The duties of the Medical Staff Executive Committee shall be: ii) to coordinate the activities and general policies of the Departments.

Review of the hospital's job description for, "Chief Nursing Officer," dated 10/09/17, showed ..."ensure that patient care delivery models and standards of nursing practice are consistent with current professional standards...consults with staff, physicians, and other nursing units on nursing problems and interpretation of Hospital policies and procedures to ensure that patient needs are met...coordinates, through clinical management personnel, the establishment of major schedules, task assignments, and allocation of manpower and equipment to ensure conformance with specified objectives and policies".

Document review of hospital's policy titled "Patient Assessment/Reassessment", revised 06/11/09, showed the assessment process begins with admission and proceeds through discharge and all patients are to be reassessed throughout the care process and at "specified intervals to ensure care decisions remain appropriate." The policy also showed the nurse is to reassess the patient more frequently depending on the patient acuity determined by the Registered Nurse (RN) in charge of the patient's care.


Document review of hospital's policy titled "Scope of Service: Medical/Surgical Unit", revised 08/19/09, showed the services provided on the medical surgical unit serves mostly adult populations undergoing orthopedic, urologic, gastro-intestinal, or plastic surgery and diagnosis can include respiratory, neurological, and other diagnosis. The unit operates 24 hours per day, seven days per week and the labor budget for nursing is built upon a nurse to patient ratio of "preferred 1:4 to maximum of 1:6. The staff is all RN."

The hospital failed to provide adequate staffing to provide nursing services to meet patient needs in accordance with accepted standards of practice and hospital policy. Refer to A-0385.

The hospital failed to provide nurse staffing sufficient to meet patient needs and provide safe care based on continuous assessments in one of ten medical records reviewed (Patient 1). Refer to A-0392.

The hospital failed to ensure the nursing staff evaluated the care for each patient on an ongoing basis in accordance with accepted standards of nursing practice and hospital policy for one of ten records reviewed (Patient 1). Refer to A-0395.

Based on observation and interview, the hospital failed to ensure confidentiality of patient information by ensuring all information is inaccessible to unauthorized individuals for seven (Patients 15, 16, 17, 18, 19, 20, 21) of 19 patient's personal information.

The failure of hospital staff to ensure they protect all patient information from unauthorized access places patients at risk of loss of confidentiality.

Findings Include:

Document review of hospital policy titled "Patient Privacy and Confidentiality" revised 12/12/11, showed "patient information is to be restricted to a need to know and staff are not to leave a computer unattended with patient information visible and are to log out of patient information prior to leaving a computer".

Observation on 09/11/19 at 4:45 AM in hallway 105 showed the previous user had not logged out of one of two computer screens which displayed patient information leaving Patient 15, 16, and 17's information accessible to unauthorized individuals.

During an interview on 09/11/19 at 4:50 AM, Staff D, RN stated she normally logs out of the patient records when she is leaving the computer station and stated she is aware patient information is not to be accessible to anyone without authorization to access it.

Observation on 09/11/19 at 5:00 AM in hallway 109 showed one of two computer stations that someone had taped a piece of paper to the top of the computer monitor so it hung down and covered a portion computer screen. Flipping up the paper showed the previous user had not logged out of Patient 18, 19, 20, and 21's information which allowed the information to be accessible to unauthorized individuals.

During an interview on 09/11/19 at 5:00 AM, Staff E, RN stated she was aware no one without authorization is to access patient information and acknowledged the paper hanging over the front of the computer screen does not keep anyone to access the information. Staff E stated that they are supposed to log out, but they don't because it takes so long to log back in.

During an interview on 09/11/19 at 10:00 AM, Staff A, Chief Nursing Officer (CNO) stated she was disappointed this was an issue because a hospital wide email had been sent with a copy of the policy within the last couple of months and staff were directed to review it.

Based on medical record review, document review and staff interview the hospital failed to provide nurse staffing sufficient to meet patient needs and provide safe care based on continuous assessments in one of ten medical records reviewed (Patient 1) and failed to ensure the nursing staff evaluated the care for each patient on an ongoing basis in accordance with accepted standards of nursing practice and hospital policy for one of ten records reviewed (Patient 1).

The cumulative effect of this deficient practice places patients at risk for worsening of conditions, unsafe care and and potential for death.


Findings Include:

1. The hospital failed to provide nurse staffing sufficient to meet patient needs and provide safe care based on continuous assessments in one of ten medical records reviewed (Patient 1). Refer to A-0392.

2. The hospital failed to ensure the nursing staff evaluated the care for each patient on an ongoing basis in accordance with accepted standards of nursing practice and hospital policy for one of ten records reviewed (Patient 1). Refer to A-0395.

Based on observation, record review, document review, and interview the hospital failed to provide nurse staffing sufficient to meet patient needs and provide safe care for one of ten medical records reviewed (Patient 1). The Hospital failed to base nurse staffing on patient acuity, patient volume, patient location, and nurse ability and experience.

Findings Include:

Document review of hospital policy titled "Scope of Service: Medical/Surgical Unit" (Med/Surg.), revised 08/19/09, showed the services provided on the medical surgical unit serves mostly adult populations undergoing orthopedic, urologic, gastro-intestinal, or plastic surgery and diagnosis can include respiratory, neurological, and other diagnosis. The unit operates 24 hours per day, seven days per week and the labor budget for nursing is built upon a nurse to patient ratio of "preferred 1:4 to maximum of 1:6. The staff is all Registered Nurses (RN)."

Document review of hospital policy titled "Patient Assessment/Reassessment" revised 06/11/09, showed the assessment process begins with admission and proceeds through discharge and all patients are to be reassessed throughout the care process and at "specified intervals to ensure care decisions remain appropriate." The policy also showed the nurse is to reassess the patient more frequently depending on the patient acuity determined by the RN in charge of the patient's care. The policy failed to include information for the nursing staff as to when to notify the physician of a change in patient condition.


Document review of the med/surg. unit staff schedule dated 08/13/19 7:00 PM to 7:00 AM showed RN staff to patient ratio was 1:5 with a total of 15 patients and three RN's on the unit, Staff D, E and F.

Observation of the medical surgical (med/surg.) unit during a tour on 09/09/19 at 9:30 AM showed the unit consists of six, four patient units laid in a pattern such that a staff member is unable to visualize more than four patient rooms from any hallway work station.

Document review of Staff D, RN's, nursing assignment dated 08/13/19 showed she was assigned to five patients on three different halls which included the following patients:

1. Patient 1, admitted for dehydration with uncontrolled movements and an aspiration risk and located in room number w202 on hallway 201. Patient 1 had nausea and vomiting at the start of the 7:00 PM shift and was an aspiration risk.

Review of Patient 1's medical record showed he was admitted on 08/08/19 with a complaint of dehydration. The patient has a past medical history that includes Huntington's Disease (a fatal genetic disorder that causes the progressive breakdown of nerve cells in the brain). Patient 1's guardian brought him to the hospital after he had significant weight loss that occurred while at his group home. Due to the patient's loss of fine motor skills he was unable to meet his dietary needs with self-feeding.

On 08/09/19, Staff O, Speech Therapist conducted Patient 1's bedside swallow study. Review of Staff O's swallow exam assessment showed, "At this time, pt. [patient] presents with ability to swallow thin liquids given in small sips (i.e., one sip at a time) and very soft foods. Pt does present with overall increased risk of aspiration (breathing in food or fluids when you swallow, vomit or experience heartburn) related to weakness, decreased coordination of swallowing/breathing and inability to chew. Recommend continue with PO (oral) intake, but question ability to meet nutritional needs with only PO nutrition." Recommendation included that no hard or crunchy foods be given, and patient is to be given chopped meat, cut into small bite sized pieces, moisten meat. Patient 1 was to be fed with one-person assistance."

The medical record showed a Percutaneous Endoscopic Gastrostomy (PEG) (a tube placed through the abdomen directly into the stomach for feeding), was surgically placed on 08/12/19. Also, on 08/12/19, Patient 1 was placed in an Enclosure bed (a bed that may be used for patients who are at high risk for falls; are confused, impulsive, restless, or agitated; are unable to ask for assistance or respond to redirection; or who climb out of bed when it's unsafe to do so) to protect the patient from falling because of his spastic involuntary movements.


On 08/13/19 between 1:00 and 3:00 PM, Staff J, RN, documented in a Progress Note that Patient 1 received his first PEG tube feeding of Two Cal (a liquid nutrition) through his feeding tube, even though he had been given Zofran (a medication used to treat nausea and vomiting) 4 milligrams (mg) intravenous (IV) push at 5:55 AM, 6:25 AM, 3:01 PM and 3:31 PM for nausea. Staff J also documented in a Progress Note on 08/13/19 that between 4:00 PM and 6:00 PM the patient's guardian was there and had brought the patient a large shake...The guardian was updated on the patient's condition and advised he had nausea and was just medicated. Guardian was asked to hold off on the shake. He did not. Patient tolerated the shake and then wanted chicken and mashed potatoes. Patient kept belching. Head of the bed was elevated. Patient vomited an undetermined amount of green foul-smelling emesis (vomit). Patient was cleaned up and would only lay on his stomach. Staff J, RN, further documented in the "Progress Note" dated, 08/13/19 that at 7:30 PM Patient 1 had vomited a small to moderate amount of a green foul-smelling substance.

During an interview on 09/11/19 at 10:30 AM Staff J, RN stated that nursing assignments are not always for patients on the same hallway. She stated, "he [Patient1] possibly should have been 1:1 even with the enclosure bed" but it was difficult to get sitters and there is a lot of traffic on the hall during the day. She stated "administration is always wanting to make everything equal and if one area is short-staffed then they pull from an area that is not short staffed to equal the staffing throughout. She stated that she was grateful the guardian was sitting with Patient 1 because she had other patients she needed to take care of.

During an interview on 09/17/19 at 10:00 AM, Patient Guardian (PG) 1, stated that Staff J, RN told him when he got into Patient 1's room at about 1:30 PM that he had just vomited, and he shouldn't give Patient 1 the milkshake. PG 1 stated he told the nurse he would be careful and stated that he only gave Patient 1 a couple of sips of the milkshake and then he didn't want it, so PG 1 dumped it into the sink. PG 1 stated that Staff J, RN ordered a tray of chopped-up chicken and mashed potatoes with gravy after asking Patient 1 if he wanted to try that. PG 1 stated that he fed Patient 1 the meal and that he ate most of it. PG 1 stated that the nurse came back into the room and offered dessert and ordered apple pie, but Patient 1 only ate a bite of it. PG 1 stated that he had taken care of patients with Huntington's disease for 33 years and knew how to feed Patient 1 but stated the hospital staff did not ask if he knew how to feed Patient 1 safely. PG 1 stated that the head of the bed was elevated when he left the hospital at about 6:30 PM.

Review of the "Progress Notes" dated 08/13/19 at 9:25 PM showed Staff D, RN documented that she obtained the patient's vital signs and Patient 1 reported he felt nauseated. Patient 1 wanted to wait an hour before taking medications. Staff D, RN, documented in the "Assessments and Treatments" dated 08/13/19 at 9:30 PM that the head of bed was flat, and Patient 1 had a food/liquid swallowing problem, nasal congestion, was anxious, does not follow commands, impulsive, restless, and self-injurious, with weakness.

Review of a "Progress Note" dated 08/13/19 at 10:30 PM, showed Staff D, RN entered Patient 1's room and found him unresponsive face down in vomit. Staff D called the Quick Response Team and began resuscitation efforts which were unsuccessful.

During an interview on 09/11/19 at 8:15 AM, Staff D, RN stated, "I did a quick assessment at 7:00 PM" and stated that when she went back to his room Patient 1 was asleep. She stated that she went in Patient 1's room around 9:00 PM because he had medication due she stated that she asked him if he was still nauseated and that she didn't want to give him anything if he was. She wanted to wait an hour before she gave him medications. She stated that she put him on his side and before she left the room, he was back on his stomach. She stated that she thought the head of the bed was level at that point and that his door was always open. She stated she saw him at about 9:30 PM and he was moving around in bed. At about 10:30 PM Staff D stated she took medications to him and that was when she found him face down on his stomach in a pool of vomit." She stated she immediately called a code, but he could not be resuscitated. " She also stated, "the whole incident was tragic, but I feel we did the best we could, extra staff would have helped."

Staff D, RN, further stated that her other assignments on the night Patient 1 died included a total of five patients on three different hallways. Two patients that were newly post-operative, one of which was a spinal surgery requiring frequent pain medications, one disoriented patient who kept getting out of bed and had a bed monitor, one patient who removed his PEG feeding tube and was a two person assist for cares, and one patient who required pain management.


2. Patient 11, admitted on post-operative day zero with a right total hip replacement located in room number w101 on hallway 101. Patient 11 required pain medication, dangling, and management of the hemovac (a drain to remove fluids after surgery). Patient 11 was diabetic and required a blood sugar check and insulin.

3. Patient 12, admitted with pancreatitis (inflammation of the pancreas) and gallstones located in room number w102 located on hallway 101.

During an interview on 09/11/19 at 8:00 AM, Staff D, RN, stated that Patient 12 had an Ensure (nutritional supplement drink) which caused the patient to have several loose bowel movements requiring a two person assist to change the patient and the bedding. The Patient 12 required frequent repositioning and was an aspiration risk.

4. Patient 13, admitted with a G-tube (a tube place into the stomach through the skin for feeding) difficulty and a stroke located in room number 103 located on hallway 101. Patient 13 had diabetes and required a blood sugar check and insulin.

During an interview on 09/11/19 at 8:00 AM, Staff D, RN, stated that Patient 13 was confused and required a lot of checks, and "I was afraid they wouldn't stay in the bed."

5. Patient 14, admitted on post-operative day zero with back surgery located in room number w111 on hallway 109. Patient 14 required pain medication.

During an interview on 09/09/19 at 10:00 AM, Staff B, RN, stated that Staff C, Physician, did not want to continue to use a sitter for Patient 1 after the weekend because the patient was needing placement and having a sitter complicates placement. Staff B stated, " I believe that if we had had a sitter the incident was preventable. I think that his disease was progressing, but we could have given him more time if we had had a sitter." Staff B stated that the night of the incident the hospital scheduled five RN's to work the 7:00 PM to 7:00 AM shift however one RN called in and telemetry called and requested one RN because they were short staffed. That RN subsequently quit on the spot leaving three RNs for 15 patients. The patients located in multiple hallways were divided among the remaining RN's resulting in two of the remaining three RN's to have patients on three separate hallways. They were physically unable to see or hear a call light unless they were on the same hallway with the patient in need of assistance. The hospital does not have a house supervisor or lead that they can call for assistance. Staff B then stated, "Based on what happened that night I do believe this type of thing could happen again." She further stated that management sets the patient to nurse ratio and the current matrix is set at a minimum of 4:1 with a maximum of 6:1 patient to nurse ratio. Since we are primary nursing and there is no support staff. It is very labor intensive. Staff B further stated this kind of incident could "definitely happen again unless staffing is increased."

During an interview on 09/10/19 at 11:00 AM, Staff C, Physician, stated, "We didn't want to use a sitter because that does make placement harder." Staff C stated that a patient needing placement can play a role in whether they choose to use a sitter for them or not. Since Patient 1 was there for help with placement that would have made it even harder. Staff C stated, "We already had a lot of hard No's". Staff C stated, "I do believe that not being able to use a sitter can place patients at risk".

During an interview on 09/09/19 at 1:10 PM, Staff A, Chief Nursing Officer (CNO) stated, "we definitely recognize we are in a staffing crisis," and further stated the hospital is staying with the primary nurse model. She further stated that staff were interviewed following Patient 1's death and have determined the cause of death was "staffing, in that his primary nurse was assigned to patients on three different units and was unable to respond to his needs." She further stated maybe "he should have been moved to intensive care or have a sitter with him all of the time, but the problem is who would that be?" Staff A stated patient assignments are made by the charge nurse who know the abilities of the nurses assigned on each shift and the charge nurse is usually deemed to be the longest and strongest nurse on the shift.

During an interview on 09/11/19 at 4:45 AM, Staff E, RN stated each nurse determines the frequency of the nursing assessment for each patient but staffing levels would not allow an RN to stay with any patient one on one unless a sitter was provided, or the patient was moved to the Intensive Care Unit (ICU). The night of Patient 1's death, Staff E stated the nursing staff was short because the telemetry unit manager needed an RN and pulled one of ours to work on their unit. The RN subsequently quit. She further stated staffing has been short for "some time" and the hospital tries to fill in with agency staff, but even they are no longer available. Staff E stated, "patient safety is absolutely at risk at a 6:1 ratio." She stated that staffing potentially contributed to Patient 1's death. The physical hospital layout is intended to provide care to four patients only.


During an interview on 09/11/19 at 2:30 PM, Staff L, MD stated the hospital nursing model is primary nursing is four patients to one RN and a maximum of six patients to one staff RN. He stated that scheduling is left up to the managers "to decide if the staffing is safe." He stated "That's news to me that the nurses and managers are saying they are not assigning patients based on acuity. That would make no sense to me." Staff L stated that he could not argue that point because he did not have a scale to prove that hospital uses acuity as a guide for nurse staffing. Staff L stated that it was up to the unit managers to decide what was the appropriate staffing level with four patients to one nurse being the minimum and six patients to one nurse the maximum. Staff L, MD stated he did not know Patient 1 but was aware of the situation second hand. Following the death there was a root cause analysis conducted and stated, "in hind sight the care was not sufficient" because this patient was at higher risk for vomiting and unable to call for help. He stated every RN has the right to say there are insufficient resources for the number of patients assigned.

Based on medical record review, document review and staff interview the hospital failed to ensure the nursing staff evaluated the care of one of ten patients reviewed (Patient 1) on an ongoing basis in accordance with accepted standards of nursing practice and hospital policy.


Findings Include:


Document review of the hospital's policy titled "Patient Assessment/Reassessment", revised 06/11/09, showed the assessment process begins with admission and proceeds through discharge and all patients are to be reassessed throughout the care process and at "specified intervals to ensure care decisions remain appropriate." The policy also showed the nurse is to reassess the patient more frequently depending on the patient acuity determined by the Registered Nurse (RN) in charge of the patient's care. The policy failed to include information for the nursing staff as to when to notify the physician of a change in patient condition.


Review of Patient 1's medical record showed he was admitted on 08/08/19 with a complaint of dehydration. The patient has a past medical history that includes Huntington's Disease (a fatal genetic disorder that causes the progressive breakdown of nerve cells in the brain). Patient 1's guardian brought him to the hospital after he had significant weight loss that occurred while at his group home. Due to the patient's loss of fine motor skills he was unable to meet his dietary needs with self-feeding.


On 08/09/19, Staff O, Speech Therapist conducted Patient 1's bedside swallow study. Review of Staff O's swallow exam assessment showed, "At this time, pt. [patient] presents with ability to swallow thin liquids given in small sips (i.e., one sip at a time) and very soft foods. Pt does present with overall increased risk of aspiration (breathing in food or fluids when you swallow, vomit or experience heartburn) related to weakness, decreased coordination of swallowing/breathing and inability to chew. Recommend continue with PO (oral) intake, but question ability to meet nutritional needs with only PO nutrition." Recommendation included that no hard or crunchy foods be given, and patient is to be given chopped meat, cut into small bite sized pieces, moisten meat. Patient 1 was to be fed with one-person assistance."

On 08/09/19, Staff M, Dietician, documented that Patient 1 has difficulty chewing and swallows most bites of food whole, straw must be pinched for drinking liquids.

Review of hospital policies showed the hospital had no policy directing nursing staff how to supervise, evaluate, and monitor patients at risk for aspiration.

During an interview on 09/11/19 at 8:15 AM, Staff D, RN stated, the care plan for Patient 1 was not updated to show that he was an aspiration risk, care plans are typically started at admission and "aspiration was not added to the care plan."

Patient 1's record failed to show evidence that any order was written regarding him being an aspiration risk or providing the nursing staff feeding instructions from the Speech Therapist or the Dietician.


Patient 1's medical record showed a Percutaneous Endoscopic Gastrostomy (PEG) (a tube placed through the abdomen directly into the stomach for feeding), was surgically placed on 08/12/19.


According to the Journal for Parenteral (through the vein) and Enteral (through the gastro-intestinal (GI) tract) Nutrition. 2017;41(1): 22 - 31., The hospital should develop protocols that call for "proper flushing before and after medication administration, during continuous feeding, before and after intermittent feeding, and before and after gastric residual volume (GRV - the amount of fluid aspirated from the stomach following administration of enteral feeding typically at intervals ranging from four to eight hours) measurements" ... "Address reassessment of the appropriateness of Head of Bed (HOB) elevation and ongoing monitoring for Enteral Nutrition tolerance" ... "Ongoing monitoring includes laboratory monitoring, measurement of intake and output, weight measurements, physical assessment, and GI tolerance."


The hospital failed to have nursing policy and procedures for the administration of tube feeding through a feeding tube or protocols directing staff on the proper flushing before and after medication administration, during continuous feeding, before and after intermittent feeding, and before and after gastric residual volume (GRV - the amount of fluid aspirated from the stomach following administration of enteral feeding typically at intervals ranging from four to eight hours) measurements" or protocols addressing reassessment of the appropriateness of HOB elevation and ongoing monitoring of tube feeding tolerance. Feeding tubes place patients at risk for nausea, vomiting and aspiration. The lack of policy and procedures that direct staff regarding the proper supervision, evaluation, and monitoring of a patient receiving tube feeding places the patient at a greater risk for complications.


During an interview on 09/09/19 at 1:10 PM, Staff A, Chief Nursing Officer (CNO) stated when bolus (intermittent) tube feedings are ordered the nurse should monitor the patient for at least 15 minutes following the feeding and keep the head of the bed elevated, however she clarified there is no hospital policy or procedure for bolus tube feeding administration.


Patient 1's medical record showed an order for Zofran (a medication used to treat nausea and vomiting) 4 milligrams (mg) = 2 ml (milliliter), IV (intravenous) push every six hours as needed for nausea and vomiting). The medication administration record showed Patient 1 received 4 mg of Zofran four times on 08/13/19 at 5:55 AM, 6:25 AM, 3:01 PM and 3:31 PM for nausea and vomiting. Two of the doses of Zofran were given more frequent than every 6 hours. There was no documented evidence in the medical record of a doctor's order to increase the frequency of Zofran or notification to the physician of Patient 1's nausea and vomiting.

Review of a Progress note written by Staff N, Medical Doctor (MD) dated 08/13/19 at 10:40 AM, showed: "doing well post-op (after surgery). Appears largely unchanged. The Impression and Plan showed: "Doing well, begin TF (tube feeding) today." There was no documented evidence in this physician progress note that showed the physician was aware that Patient 1 had nausea although Patient 1 had received two doses of Zofran earlier in the day.

Review of a Progress note written by Staff K, MD, dated 08/13/19 at 1:37 PM, showed: "Patient not always aspirating but is high risk for aspiration and obviously not able to get adequate nutrition. PEG tube place 08/12/19. Started TF (tube feeding) today - watch for refeeding syndrome (a potentially fatal condition that affects patients who are starved or severely malnourished, symptoms may include fatigue, weakness, confusion, inability to breath, high blood pressure, seizures and irregular heart beat). There was no documented evidence in this physician progress note that showed the physician was aware that Patient 1 had nausea although Patient 1 had received two doses of Zofran earlier in the day.

Review of "Nutrition Care" dated 08/13/19 at 2:09 PM, by Staff M, Dietician, showed, spoke to Staff N, MD, pt. ready to start TF. Rec. [recommend] bolus dt [due to] concern of pt. pulling on tube. Per MD will continue taking PO meals and supplementing nutrition with TF. There was no documented evidence in the nutrition note that showed the dietician was aware that Patient 1 complained of nausea and was given two doses of Zofran earlier in the day.

On 08/13/19 between 1:00 and 3:00 PM, Staff J, RN, documented in a Progress Note that Patient 1 received his first PEG tube feeding of Two Cal (a liquid nutrition) through his feeding tube, even though he had been given Zofran for nausea. Staff J also documented in a Progress Note on 08/13/19 that "between 4:00 PM and 6:00 PM the patient's guardian was there and had brought the patient a large shake...The guardian was updated on the patient's condition and advised he (Patient 1) had nausea and was just medicated. Guardian was asked to hold off on the shake. He did not. Patient tolerated the shake and then wanted chicken and mashed potatoes. Patient kept belching. Head of the bed was elevated. Patient vomited an undetermined amount of green foul-smelling emesis (vomit). Patient was cleaned up and would only lay on his stomach. Staff J, RN, further documented in the "Progress Note" dated, 08/13/19 that at 7:30 PM, "Patient 1 had vomited a small to moderate amount of a green foul-smelling substance".


During an interview on 09/11/19 at 10:30 AM Staff J, RN stated Patient 1 was an aspiration risk and "we would pinch the drinking straw to slow his fluid intake and would take the glass away from him, so he would not gulp down the fluid too fast. He also required feeding assistance because his gross motor skills were uncontrolled, and he was unable to get food to his mouth without assistance." Staff J stated she gave him his first tube feeding through the PEG tube at about 4:00 PM and he sat up in his bed and watched her give it. She stated sometime after the tube feeding his guardian came to the room with a milk shake and she stated, "I told him to hold off on giving him anything because I had just given the tube feeding and he was burping some." She stated the guardian shut the door when Staff J left the room and when she returned the milk shake was gone and an empty food tray was in the room. She stated that the guardian told her he had given it to Patient 1. She stated, "I was grateful the guardian was in there sitting with Patient 1 because I had other patients to take care of." She stated that Patient 1 then vomited twice after the food and tube feeding at about 7:00 PM. Staff J stated that she gave report to the Staff D, RN and she said the head of the bed was elevated 25 to 30 degrees.

During an interview on 09/17/19 at 10:00 AM, Patient Guardian (PG) 1, stated that Staff J, RN told him when he got into Patient 1's room at about 1:30 PM that he had just vomited, and he shouldn't give Patient 1 the milkshake. PG 1 stated he told the nurse he would be careful and stated that he only gave Patient 1 a couple of sips of the milkshake and then he didn't want it, so PG 1 dumped it into the sink. PG 1 stated that Staff J, RN ordered a tray of chopped-up chicken and mashed potatoes with gravy after asking Patient 1 if he wanted to try that. PG 1 stated that he fed Patient 1 the meal and that he ate most of it. PG 1 stated that the nurse came back into the room and offered dessert and ordered apple pie, but Patient 1 only ate a bite of it. PG 1 stated that he had taken care of patients with Huntington's disease for 33 years and knew how to feed Patient 1 but stated the hospital staff did not ask if he knew how to feed Patient 1 safely. PG 1 stated that the head of the bed was elevated when he left the hospital at about 6:30 PM.

Patient 1's medical record failed to show evidence that Staff J took steps to prevent the guardian from providing Patient 1 the shake or a plate of food when the patient was belching, nauseated, and had just been given medication to treat the nausea and failed to document specific instructions to the guardian related to the recommendations from the swallow study. There was no documented evidence in the medical record to show Staff J notified the physician of the patient's foul-smelling emesis.


Review of a Progress note dated 08/13/19 at 9:20 PM showed that Staff D, RN documented that she obtained the patient's vital signs and Patient 1 reported he felt nauseated. Patient 1 wanted to wait an hour before taking medications.

There was no documented evidence in the medical record that showed Staff D checked the patient's gastric residual volume (GRV) to see if he was tolerating his tube feeding. The "Assessments and Treatments" dated 08/13/19 at 9:20 PM showed that the head of bed (HOB) was flat, and Patient 1 had a food/liquid swallowing problem, nasal congestion, was anxious, does not follow commands, impulsive, restless, and self-injurious, with weakness.

Additionally, the nursing staff failed to provide Patient 1 with a call light that he was able to use. Patient 1 was unable to use a regular call light due to loss of fine motor control because of his advanced disease process. So, Patient 1 had no way to alert staff of his needs or an emergency other than to verbally call out for help.

During an interview on 09/11/19 at 4:45 AM, Staff E, RN stated their call light system doesn't include a notification to their phone so if they are not on the hallway that has a call light they wouldn't know about it until the unit clerk or someone else notifies the RN.

During an interview on 09/11/19 at 10:30 AM, Staff J, RN, stated that Patient 1 did have a call light near him, but he could not always hit it because of his uncontrolled movements. Staff J stated that he did not have fine motor skills. Staff J stated, "We tried him on a stroke call light that required him to hit the button with head movement and he did not like it and threw it, so we gave the regular call light back to him. He had no other way to call for help and probably should have been placed on a one to one observation.

During an interview on 09/10/19 at 1:45 PM, Staff A, Chief Nursing Officer (CNO), Stated, "Putting him on one to one observation would have been the most ideal situation."

There is no documentation between Staff J's final charting on 8/13/19 at 7:30 PM and Staff D's documentation on 08/13/19 at 9:30 PM to show how the HOB went from 25 to 30 degrees to flat. Patient 1 was unable to adjust the HOB on his own because he lacked fine motor control. Leaving the patient's HOB flat, places the patient at a higher risk for aspiration than if the HOB was elevated. Nursing staff failed to ensure the HOB was elevated to reduce Patient 1's aspiration risk.

The medical record failed to show the nurse conducted a cardiovascular, respiratory or gastrointestinal assessment between 08/12/19 at 9:00 PM and 08/13/19 at 9:20 PM, in the Assessment sections of the medical record.


During an interview on 09/11/19 at 8:15 AM, Staff D, RN stated, "I did a quick assessment at 7:00 PM" and stated that when she went back to his room, Patient 1 was asleep at 8:00 PM. She stated that she went in Patient 1's room around 9:00 PM because he had medication due she stated that she asked him if he was still nauseated and that she didn't want to give him anything if he was. She wanted to wait an hour before she gave him medications. She stated that she put him on his side and he was back on his stomach before she left the room. She stated that she thought the head of the bed was level at that point and that his door was always open. She stated she saw him at about 9:30 PM and he was moving around in bed. At about 10:30 PM Staff D stated she took medications to him and that was when she found him face down on his stomach in a pool of vomit." She stated she immediately called a code, but he could not be resuscitated. "


During an interview on 09/11/19 at 4:45 AM, Staff E, RN stated each nurse determines the frequency of the nursing assessment for each patient but staffing levels would not allow an RN to stay with any patient one on one unless a sitter was provided, or the patient was moved to the Intensive Care Unit (ICU). Staff E stated if she had a patient who was identified as an aspiration risk and family brought food to that patient she would educate the family and observe them feeding the patient before they would be allowed to independently give food or drink. She also stated, "she has not had a patient requiring a tube feeding before and does not know how long to monitor the patient following the feeding."


During an interview on 09/11/19 at 2:30 PM, Staff L, MD stated he did not know Patient 1 but was aware of the situation second hand. Following the death there was a root cause analysis conducted and stated, "in hind sight the care was not sufficient" because this patient was at higher risk for vomiting and unable to call for help. He stated every RN has the right to say there are insufficient resources for the number of patients assigned. Staff L further stated safety measures should be followed in an aspiration risk patient and no fluids or anything they can swallow should be allowed in the room. He further stated the RN should be checking for fluid residual prior to each tube feeding. He stated that they should be following the surgeon's orders or the attending physician's order. In hindsight the care was not sufficient. He stated that he thinks we should all learn from these things, "One this patient was higher risk for vomiting. The nurse saw the guardian giving the patient a milkshake and food. I think it should have been considered a risk. To me it should have been an alarm that his care had deviated from orders when the guardian gave the patient a shake and a meal. There should have been a report to higher ups."