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Based on interview and review of 1 of 1 clinical record, as part of a complaint investigation, there was a failure to supervise patient care resulting in a patient in a patient aspirating thin liquid nourishments.
Findings:

Record review reflected the patient, a 77 year old male, was transferred to this rehabilitation facility from an acute care hospital on 1/3/2010 where he was treated for volume overload and respiratory failure secondary to pneumonia. Upon admission the patient was on mechanical ventilation and fed via nasogastric tube. By 1/22/2010 the patient had been weaned from the ventilator. Per physician #50 at 8:40am on 4/8/2010, the patient and family wanted feeding by mouth even though the patient was at high risk for aspiration. Therefore, pureed foods and thick liquids were ordered. However, on 1/22/2010 it was noted the patient aspirated when personnel # 55, a certified nurse assistant (CNA) , gave the patient
thin liquids.
Prior to this on-site visit, the facility conducted an investigation of this incident and identified the CNA had not been adequately trained in feeding patients at risk of aspiration. To correct this , all CNA's were trained in this area.