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Based on record review, interviews, and observation, the governing body failed to be responsible for services furnished in the hospital in that two of two patients (Patient #1 and Patient #15) with special dietary needs had access to food restricted from their diets by medical staff orders while being monitored by "sitters" during their hospitalization.

Findings included:

1) Patient #1's admission orders dated 10/10/13 included Physician #4's order for NPO (nothing by mouth) and tube feeding.

Physician #11's consultation dated 10/14/13 noted Patient #1 had a PEG tube (feeding tube) and "...also significant dysphagia [difficulty in swallowing] and high risk for aspiration pneumonia [condition when foreign material is breathed into the lungs]." The plan of treatment included aspiration precautions.

Hospital Employee #5 was interviewed on 12/27/13 at 12:10 o'clock and confirmed an incident where Patient #1 had an emesis of solid food particles in spite of being tube fed only. Patient #1 "vomited formula and something that looked like noodles and ground meat." Patient #1 "was quick and had grabbed some food before." A day later, on 10/27/13, Patient #1's arterial blood gases "were bad and...(Physician #4) called 911 herself." The patient deteriorated and was transferred per emergency services to an acute care hospital for intubation.

During an interview on 12/27/13 at 11:10 o'clock, Hospital Employee #3 stated Patient #1 had sitters who ate their meals in the patient's room.

Hospital Employee #1 stated during an interview on 12/27/13 at 15:10 o'clock the incident "did not make it " to the Quality Department and was "overlooked."

2) Patient #15 was on a mechanical soft diet according to the Nursing Assignment sheet dated 12/27/13. Observations on the hospital's second floor patient care area on 12/27/13 at 14:00 o'clock reflected a "sitter" had a cup of coffee and lunch at Patient #15's bedside and the "sitter" stated she was planning to eat her lunch which included an apple.

Hospital Employee #1 was interviewed on 12/27/13 at 15:10 o'clock and denied care sitters had a hospital employee training file.


The hospital's Enteral Feeding and Care Policy #7:304:00 dated 2013 noted the purpose to "provide guidelines for the safe administration of Enteral Nutrient Solutions (ENS) directly into the gastrointestinal tract."

Based on record review and interviews, the hospital failed to ensure the registered nurse evaluated the care provided for one of one tube-fed patient (Patient #1) who had special dietary restrictions. Patient #1 aspirated and had food particles in his emesis on at least three occasions. The patient's condition deteriorated requiring emergency intubation at an acute care hospital the following day.

Findings included:

Patient #1's admission orders dated 10/10/13 included Physician #4's order for NPO (nothing by mouth) and tube feeding.

The LVN's (Hospital Employee #5) nurses' notes dated 10/26/13 and timed at 13:00 o'clock reflected Patient #1 vomited "a very large amount" twice. The LVN's (Hospital Employee #13) nurses' notes dated 10/27/13 at 03:30 o'clock noted Patient #1 had vomited "...large amounts of mustard yellow emesis with what appears as chunks of food in it..."

Hospital Employee (LVN) #3 stated during an interview on 12/27/13 at 11:10 o'clock that Patient #1 had sitters who ate their meals in the patient room.

Physician #4 was telephone interviewed on 12/27/13 at 11:13 o'clock and stated she had received a nurse report that the patient had vomited solid foods "...like meat and noodles." Hospital Employee (LVN) #5 and Hospital Employee (RN) #6 had knowledge of the incident. The physician stated Patient #1 "...was well that morning but decompensated due to aspiration and it was implied that the incident happened at the hospital."

Hospital Employee (LVN) #5 was interviewed on 12/27/13 at 12:10 o'clock and stated on Saturday (10/26/13) around lunch time Patient #1 "...vomited formula and something that looked like noodles and ground meat..." The nurse stated she had previously observed that Patient #1 "was quick and grabbed some food." Hospital Employee (LVN) #5 stated she did not document that the emesis looked like food but it looked like "regular egg noodles and goulash." Hospital Employee (LVN) #5 stated she reported the incident to Hospital Employee (RN) #6, the registered nurse in charge.

Hospital Employee (RN) #6 was telephone interviewed on 12/27/13 at 14:35 and confirmed the incident of Patient #1's emesis of "clumps of something." Hospital Employee (LVN) #5 had reported to her that "somebody fed him [Patient #1] the food."

The hospital's Enteral Feeding and Care Policy #07:304:00 dated 2013 noted the purpose to "provide guidelines for the safe administration of Enteral Nutrition Solutions (ENS) directly into the gastrointestinal tract."