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Based on medical record review, event report review, staff and physician interviews, the hospital failed to monitor and track staff education and the confirmation of patient diet orders after an adverse event in the ED for 1 of 1 adverse patient events reviewed.(Patient #10)

The findings included:

Review on February 9, 2021 of the closed medical record for Patient #10 revealed, a [AGE]-year-old female arrived at the Emergency Department (ED) via Emergency Medical Services (EMS) on October 20, 2020 at 10:13 AM. Record review revealed a Transfer Report from Patient #10's Long Term Care (LTC) facility was given to ED Registered Nurse (RN) #1 upon Patient #10's arrival. Review of the document revealed, Patient #10 had a Do Not Resuscitate (DNR) status and was on a Pureed Diet. The Transfer Report further revealed that Patient #10 had several diagnoses including, Anoxic Brain Damage and Dysphagia (Difficulty swallowing). Review of the H&P (History and Physical) written by Medical Doctor (MD) #1 at 10:18 AM revealed, Patient #10's past medical history was obtained "from EMS, LTC facility paperwork" and included, dysphagia, dementia, traumatic brain injury and anoxic brain damage. Review of the Physical Exam performed by MD #1 at 10:22 AM revealed, Patient #10's Cardiovascular exam showed a regular rate and rhythm, no gallops, murmurs, or rubs. The Respiratory exam showed Patient #10 had no increased effort with breathing, exhibited no signs of respiratory distress. Review of the Triage Assessment started by ED RN #1 at 10:49 AM revealed, Patient #10 was assigned a Glasgow Coma Score (GCS - assesses a patient's level of consciousness) of 10, indicative of a moderate brain injury. Review of a Nurse Assessment by ED RN #2 at 11:15 AM revealed, Patient # 10 had a patent airway with even and unlabored breathing pattern. Record review further revealed a Behavioral Health (BH) Patient Observation sheet with every (q) 15 minute checks documented by the ED Sitter from 10:15 AM through 11:53 AM. The BH Patient Observation sheet revealed at 11:45 AM the ED Sitter documented Patient #10 was in the exam room, "with Nurse, with Physician, choking." Physician Documentation by MD #1 at 11:55 AM stated, "...patient in ED...was nodding and gesticulating that she was hungry was given food...the patient became bradycardic, hypoxic and expired at 1153a..."

Review of the Event Report completed on October 21, 2020 by ED RN #3 revealed an investigation related to Patient #10's death was conducted. The investigation summary revealed, the ED Sitter gave Patient #10 a grilled cheese sandwich and french fries for lunch. The Event Report revealed, Patient #10 had almost finished lunch when the ED Sitter noticed the patient leaning over. Review further revealed that the ED Sitter went into the room to check on Patient #10, noticed her eyes had rolled back in her head and called for help. The post event review of the Transfer Report from the LTC facility revealed Patient #10 was on a pureed diet.

Review of an ED Safety Huddle Sheet dated October 21, 2020 revealed, "...Patient Alerts or Safety Concerns...Confirm diet orders on all pts prior to feeding..." The ED Safety Huddle Sheet failed to reveal attendance by any ED day shift staff.

Interview on February 9, 2021 at 2:31 PM with ED RN #3 revealed, diet orders were not routinely put in for ED patients. Follow-up interview on February 10, 2021 at 1:20 PM revealed, "...I don't recall anything being talked about in Safety Huddle." Interview failed to reveal all staff received the information presented in Safety Huddle on October 21, 2020. Interview revealed no monitoring or tracking of patient diets being confirmed with the physician has been implemented.

Interview on February 9, 2021 at 3:38 PM with the ED Nurse Director revealed, "I would expect nurses to look at the information (Facility Transfer Reports)..." The ED Nurse Director admitted that she did not give specific instructions to the Charge Nurses (CN's) about how long the information was to be discussed at Safety Huddle. Follow-up interview on February 10, 2021 at 3:57 PM revealed, random checks by the ED Nurse Director confirmed Safety Huddle was not being done consistently. Interview revealed no monitoring of diet orders or tracking of staff education related to obtaining a diet order had been implemented to date.

Telephone interview on February 10, 2021 at 10:35 AM with ED RN #2 revealed, diet orders were not usually in the system.

Interview on February 10, 2021 at 10:57 AM with the ED Medical Director revealed, "...Cardiac arrest is the endpoint, but anything could've happened prior to that. Would need an autopsy to tell for sure...Yes, aspiration can cause cardiac arrest..." The ED Medical Director admitted that the ED physicians all know "we need to do a better job at determining appropriate diets...In this case we received conflicting information from the facility. The transfer form said, 'Pureed Diet'..." Interview revealed the facility's transfer paperwork was not reviewed for Patient #10's diet information until after the event. Interview further failed to reveal any new policies related to physicians placing diet orders for ED patients.

Telephone interview on February 10, 2021 at 11:26 AM with ED RN #1 revealed, the nurse did receive the report from EMS that day and had documented that the patient had Dysphagia. ED RN #1 stated that a patient's diet was not typically transcribed into the EMR. Interview further revealed, that the ED Sitter would know if it was okay to give food to a patient if they asked the RN or MD, but in this case, "the sitter did not ask me. I did not know until after the event...If someone would've asked, I would have told them 'No' or 'ask the Doc' because the patient had Dysphagia." ED RN #1 revealed,"...I'm not aware of any discussions or education after the fact." Interview revealed that not all ED staff were present during the Safety Huddle on October 21, 2020 and not all staff had received and attested to the SBAR communication presented on February 9, 2021.

Interview on February 10, 2021 at 1:34 PM with the Risk Manager revealed "Staff are supposed to sign the huddle sheets to show that they've read the information, but they have not been doing that consistently." Interview revealed the only Safety Huddle with the information related to confirming diet orders was done on October 21, 2020. Interview revealed no evidence of tracking or monitoring education given at Safety Huddles.

Telephone interview on February 10, 2021 at 2:02 PM with MD #1 revealed no awareness of Patient #10 having Dysphagia. MD #1 stated, "If a patient requests food from staff, they typically ask me verbally. In this case, no one did...I've thought about things afterwards and wondered...Should we put diet orders in for everyone?" Interview revealed there were no administrative or medical staff meetings after the event. MD #1 revealed the medical staff had not come up with any major changes to make since this event. Interview revealed, "Ultimately it should come down to the provider reviewing the information." MD #1 admitted that the LTC Facility's paperwork was not reviewed. The interview failed to reveal any new policies or procedures were put into place related to ED providers confirming a patient's diet with the sending facility or feeding patients in the ED as of February 10, 2021 (survey exit date).

NC 897