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HARRISON MEDICAL CENTER 2520 CHERRY AVENUE BREMERTON, WA 98310 July 2, 2020
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on interview and document review, hospital staff failed to ensure implementation of their policy for communication with family, physicians and nurses following swallow study/evaluation performed by a Speech Language Pathologist (SLP) for 1 of 5 patient records reviewed. (Patient #1)

Failure to communicate potential aspiration during a swallow study resulted in the inability of other professionls to perform assessments and ongoing care.

Findings included:

1. Document review of the "Speech Evaluation Protocol", last revised 05/20, showed that the SLP reports results of swallow evaluations directly to the attending physician, direct care staff and the patient's family.

2. Review of Patient #1's record showed that:

a) The patient had a swallow evaluation performed by the SLP on 05/19/20. On the same day at 12:59 PM, the SLP documented that "the patient was given 3 sips of milkshake, the patient had delayed audible gulping swallow which appeared to go straight to the airway. She had extensive coughing and gurgling, requiring suction each time". The SLP recommended to keep the patient NPO (nothing by mouth).

There was no documentation that the SLP (Staff #1) notified either the nurse on duty, the attending physician and the family of the patient's response to the swallow study and the suctioning that was required during the study.

On 05/19/20 at 1:53 PM, the patient was found in respiratory distress by the certified nursing assistant (CNA). The CNA (Staff #4) alerted the beside Registered Nurse (RN) (Staff #5) and the rapid response team was called to the patient's room.

On 05/19/20 at 2:11 PM, the Hospitalist physician (Staff #9) documented that it appeared the patient had aspirated on small amounts of food and secretions. The family was called about the respiratory distress at the time the rapid response team was called to help care for the patient. The patient passed away at approximately 2:15 PM. The physician notified the family of the patient's death shortly after 2:15 PM when the family arrived at the bedside.

3. On 06/30/20 at 12:48 PM, the investigator contacted the Kitsap County Coroner's office. Patient #1's cause of death was listed as: Acute Hypoxic Respiratory Failure, Secondary to aspiration. Natural death.

4. On 07/01/20 at 1:00 PM, the investigator interviewed the SLP (Staff #1). The SLP stated that they documented their findings of the swallow study but did not verbally report the results of the patient's swallow study to the attending physician and the patient's family. The SLP did tell the nurse the patient failed the swallow evaluation but did not remember telling the nurse the patient required suctioning during the evaluation.

5. On 07/02/20 at 9:15 AM, the investigator interviewed the RN (Staff #5). The RN was working the day the patient went in to respiratory distress. The nurse stated that the SLP told her the patient failed the speech evaluation but not that the patient required suctioning and that the milkshake appeared to go to the patient's airway. The RN stated that the SLP should verbally tell the RN when a patient fails a speech evaluation that resulted in the suctioning of the patient to clear their airway. The RN stated that she would need to do a patient assessment after the swallow evaluation to ensure the patient is not left in any respiratory distress. The RN would then ensure the attending physician and family were aware of the patient condition.

6. On 07/02/20 at 12:30 PM, during an interview with the investigator, the Risk Manager (Staff#7) and the Chief Nursing Officer (Staff 8) verfied the investigators findings.