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Based on record review and interview, the hospital failed to ensure therapeutic diet terminology potentially affecting five (Patients #1-5) of five patients reviewed.

This failed practice had the likelihood to result in staff confusion of therapeutic diets thereby resulting in patients receiving foods not appropriate for their swallowing ability. (See Tag A-0144)

Based on record review and interview, the hospital failed to ensure therapeutic diet for one (Patient 1) of five patients.

This failed practice had the likelihood to result in patient aspiration, infection and death. (See Tag A-0629)


Based on observation, record review and interview, the hospital failed to ensure:

1. Current diet manual for one (contracted dietary service [name omitted]) of two diet manuals reviewed.
2. Access to diet manual potentially affecting all hospital employees.

This failed practice had the likelihood to result in the inability of staff to ascertain food appropriateness for patients' diet orders. (See Tag A-0631)

Based on record review and interview, the hospital failed to ensure patient and family inclusion in care planning for two (Patients #3 and #5) of five patients reviewed.

Findings:

Patient #3

Review of medical records showed no identification of the patient's choice of family support during initial evaluation and showed no patient or family presence during care plan meetings. Specifically:

1. The "Face Sheet" document listed the contact names and phone numbers for the patient's mother and significant other.
2. The "Case Management Initial Evaluation" document dated 04/04/25 read in part, "Patient wants family/other support person contacted on their behalf," and yes was not checkmarked and no was not checkmarked. The document continued to read in part, "Consent to discuss POC/DC [plan of care/discharge]," and yes was not checkmarked and no was not checkmarked.
3. The care plan meeting document dated 04/11/25 did not show the patient, mother or significant other were present.

Patient #5

Review of medical records showed no patient or family presence during care plan meetings. Specifically:
1. The "Face Sheet" document listed the names and phone numbers of two contact people for the patient.
2. The care plan meeting document dated 06/27/25 did not show the patient or two contact people were present.

Review of a policy titled "Care Planning Reference #1055" revised on January 2018 read in part, "Patients and/or families shall be involved in care planning."

On 07/07/25 from 12:38 PM to 12:56 PM, Staff L reviewed the medical records for Patients #3 and #5 and stated:
1. They have not been including patients in care plan meetings. They have not documented the times family have attended.
2. It was important to include family in care plan meetings so they know what's going on and what to expect.
3. Family support should identified in case a patient were to have a change in condition and was no longer alert and oriented to answer questions.
4. They did not know what policy said about patient and family involvement in care plan meetings.

Based on record review and interview, the hospital failed to ensure health status to patient representative for one (Patient #4) of five patients reviewed.

Findings:

Patient #4

Review of the medical record showed no family notification for rapid response assessments and transfer of care. Specifically:

1. The "Face Sheet" document listed the contact name and phone number of the patient's daughter.
2. The "RAT Rapid Assessment Team Form" dated 02/12/25 at 11:53 AM read in part, "RAT Situation ...Change in mental status ...Family Notification N/A [not applicable]."
3. The "RAT Rapid Assessment Team Form" dated 02/15/25 at 2:37 AM read in part, "RAT Situation ...Change in mental status ...Family Notification N/A [not applicable]."
4. The "RAT Rapid Assessment Team Form" dated 02/23/25 at 11:27 PM read in part, "RAT Situation ...Low blood pressure ...Family Notification N/A [not applicable]."

On 07/07/25 from 9:38 AM to 10:20 AM, Staff F reviewed the medical record and stated:

1. Family was to be notified for change in patient condition and transfer to a higher level of care. There was no specific policy for this.
2. The patient was transferred to a higher level of care on 04/24/25 and no family notification was documented.

Based on record review and interview, the hospital failed to ensure therapeutic diet terminology potentially affecting five (Patients #1-5) of five patients reviewed.

This failed practice had the likelihood to result in staff confusion of therapeutic diets thereby resulting in patients receiving foods not appropriate for their swallowing ability.

Findings:

Review of hospital records showed no consistency in terminology used for therapeutic diets and showed language for the International Dysphagia Diet Standardization Initiative (IDDSI) as well as the National Dysphagia Diet (NDD). Specifically:

1. The hospital's OK Nutrition Manual 2021 edition read in part, "Transitional and Dysphagia Diets ...Pureed Diet (IDDSI Level 4) ...Minced & Moist (IDDSI Level 5) ...Soft & Bite Sized (IDDSI Level 6).
2. The contracted dietary service's [name omitted] Diet Manual for Long Term Care Residents 2014 Revision reviewed 02/01/25 read in part, "Mechanical Soft (Dental) Diet ...Dysphagia Level 1/Pureed Diet ...Dysphagia Level 2/Mechanically Altered Diet ...based on the National Dysphagia Diet ...Dysphagia Advanced/Level 3 Diet ...based on the National Dysphagia Diet."
3. A document titled "Inspire Specialty Hospital Dietary Orders" read in part, "Diet Consistency: Dysp 2 ground meat, Liquid Consistency: Thin, Comments: Aspiration precautions. Feeding assistance; ( potato mashed with milk, cheese and maybe chicken included, instead of mechanical soft meat can improve Pt.'s appetite.)" [NDD language]
4. The "Inspire Specialty Hospital Dietary Communication Form" read in part, "Consistency: Mechanical Soft ...Pureed ...Minced & Moist." [both IDDSI and NDD language]
5. The hospital's census sheet dated 05/06/25 read in part, "DIET ...REG/ ...GROUND."
6. A slideshow document titled "Nutrition Department" with slide titles that read in part, "SOFT DIET ...MECHANICAL SOFT DIET ...PUREED DIET." [NDD]

On 07/02/25 at 10:52 AM, Staff F stated the slideshow was used during hospital staff orientation to teach distinctions of diet consistencies.

On 07/02/25 at 12:25 PM, Staff B stated:

1. The contracted dietary service receives a dietary communication form from the hospital for each patient and enters the information into an electronic system.
2. The terminology on the dietary communication form is different from the contracted dietary service's diet manual.

On 07/02/25 from 2:38 to 3:07 PM, Staff G reviewed the Inspire Specialty Hospital Dietary Order document and stated:

1. They were familiar with IDDSI.
2. They entered the order.
3. The diet order was consistent with IDDSI terminology.
4. Diet consistency was not their department.
5. The census sheet was used by the contracted dietary service.

Based on record review and interview, the hospital failed to ensure:

1. Monitoring after an adverse patient incident for one (Patient #1) of one incidents reviewed.
2. Education after an adverse patient incident for one (Patient #1) of one incidents reviewed.

Findings:

MONITORING

Record review showed a patient received black-eyed peas while on a dysphagia 2 diet order resulting in the patient being placed on a ventilator and showed no documentation of monitoring to prevent reoccurrence. Specifically:

1. An internal facility document read in part, "Date: 5/6/2025 ...Patient becoming unresponsive ...while being assisted with [their] meal ...Respiratory Therapist used the ambuscope to visualize the patient's airway and observed whole/intact beans, black eyed peas and other food products in the patient's mouth and airway ...ETT [endotracheal tube] was inserted and the patient was placed on mechanical ventilation."

On 07/02/25 at 10:45 AM, Staff F stated:

1. They had no documentation of monitoring after the incident.
2. They had no monitoring of diet consistencies.

EDUCATION

Record review showed a patient received black-eyed peas while on a dysphagia 2 diet order resulting in the patient being placed on a ventilator and showed no documentation of education to the hospital staff of detailed descriptions of the various dysphagia diet consistencies prior to the survey. Specifically:

1. An internal facility document read in part, "Date: 5/6/2025 ...Patient becoming unresponsive ...while being assisted with [their] meal ...Respiratory Therapist used the ambuscope to visualize the patient's airway and observed whole/intact beans, black eyed peas and other food products in the patient's mouth and airway ...ETT [endotracheal tube] was inserted and the patient was placed on mechanical ventilation."

On 07/02/25 at 11:16 AM, Staff F stated education on diet and consistencies was to be provided at a skills fair in June and was not done.

On 07/03/25 at 10:05 AM, Staff J stated they had not received a whole lot of education on dysphagia diets before today.

Based on record review and interview, the hospital failed to ensure:
1. Physician notification for one (Patient #4) of five patients reviewed.
2. Hygiene for one (Patient #4) of five patients reviewed.

Findings:

PHYSICIAN NOTIFICATION

Patient #4

Review of the medical record showed the patient had a change in condition and showed no physician notification by nursing. Specifically:

1. The "RAT Rapid Assessment Team Form" dated 02/23/25 at 11:27 PM read in part, "Mental Status: Alert and oriented to person, place and time."
2. The "Nursing Shift Assessment" dated 04/23/25 read in part, "Glasgow Coma Scale ...Best Verbal Response ...Inappropriate words."
3. The "Nursing Shift Assessment" dated 04/24/25 read in part, "Glasgow Coma Scale ...Best Verbal Response ...Incomprehensible speech."

Review of a policy titled "Physician Notification of Change in Patient Condition Reference #1166" revised February 2017 read in part, "The patient's physician is notified immediately of any adverse changes in the patient's condition ...Patient Care Unit RN shall immediately notify the patient's physician of any significant change in the patient's condition, including, but not limited to: Change in level of consciousness."

On 07/07/25 at 11:00 AM, Staff F reviewed the medical record and stated:

1. Physician notification was expected for a change in condition.
2. The change in the Glasgow Coma Scale assessment warranted physician notification.
3. The risk to the patient was delay in treatment and condition deterioration.

HYGIENE

Patient #4

Review of the medical record showed the patient received no bath for 6 successive days and showed no education provided to the patient for refusal. Specifically:

1. An Activities of Daily Living (ADLs) record for bathing showed:
a. 04/11/25 No Bath
b. 04/12/25 No Bath
c. 04/13/25 Refused
d. 04/14/25 No Bath
e. 04/15/25 Refused
f. 04/16/25 Refused
g. 04/17/25 Refused

On 07/07/25 at 11:14 AM, Staff F reviewed the medical record and stated:

1. Baths were missed.
2. Documentation of education and family notification was expected if a patient refused baths.
3. It was important for this patient to receive a bath because they had a central line.

Based on record review and interview, the hospital failed to ensure therapeutic diet for one (Patient 1) of five patients.

This failed practice had the likelihood to result in patient aspiration, infection and death.

Findings:

Patient #1

Review of hospital and medical records showed the patient received black-eyed peas while on a dysphagia 2 diet order resulting in the patient being placed on a ventilator. Specifically:

1. An internal facility document read in part, "Date: 5/6/2025 ...Patient becoming unresponsive ...while being assisted with [their] meal ...Respiratory Therapist used the ambuscope to visualize the patient's airway and observed whole/intact beans, black eyed peas and other food products in the patient's mouth and airway ...ETT [endotracheal tube] was inserted and the patient was placed on mechanical ventilation."
2. A document titled "Inspire Specialty Hospital Dietary Orders" read in part, "Diet Consistency: Dysp 2 ground meat, Liquid Consistency: Thin, Comments: Aspiration precautions. Feeding assistance; ( potato mashed with milk, cheese and maybe chicken included, instead of mechanical soft meat can improve Pt.'s appetite.)
3. The hospital's census sheet dated 05/06/25 read in part, "DIET ...RENAL/THIN"
4. A rotated weekly menu showed the inclusion of black eyed peas and dinner rolls as food items provided by the hospital.
5. The [name omitted] Diet Manual for Long Term Care Residents 2014 Revision reviewed 02/01/25 read in part, "Dysphagia Level 2/Mechanically Altered Diet ...FOODS EXCLUDED ...cooked peas ...FOOD INCLUDED ...pregelled or slurried breads that are gelled throughout entire thickness of product ...FOODS EXCLUDED ...All other breads."

On 07/02/25 at 12:15 PM, Staff F stated the census sheet listed the wrong diet for the patient.

On 07/02/25 from 12:25 PM to 12:57 PM, Staff B stated:

1. Their dietary manual said cooked peas should not have been on the tray for a dysphagia 2 diet.
2. They were not sure if black eyed peas were peas.

On 07/02/25 at 2:38 PM, Staff G stated the census sheet was used by the contracted dietary service.

On 07/03/25 from 9:09 AM - 9:22 AM, Staff C was read the dietary order and stated:

1. A dysphagia 2 diet must be soft, moist, easily chewed and easily mashed. No pieces bigger than 4 millimeters. Bread must be a slurry and moist.
2. Peas should not have been included on a dysphagia 2 diet unless specified for the patient. Peas were not specified for the patient.
3. Most peas and beans were bigger than 4 millimeters. Their skins were a concern. They would need to be prepared and minced with a food processor if allowed for a patient on a dysphagia 2 diet.

On 07/03/25 at 10:15 AM, Staff A stated:

1. They were feeding the patient lunch on 05/06/25.
2. The lunch tray was spaghetti with bigger noodles and ground up meat and a whole dinner roll that did not appear moistened.
3. The patient was fine one minute while eating and the next minute was blue and they called a rapid response.

On 07/03/25 at 10:45 AM, Staff B stated:

1. The patient had peas the night before the rapid response was called.
2. Patients can have bread on a dysphagia 2 mechanically altered diet and the bread does not have to be altered.

Based on observation, record review and interview, the hospital failed to ensure:

1. Current diet manual for one (contracted dietary service [name omitted]) of two diet manuals reviewed.
2. Access to diet manual potentially affecting all hospital employees.

This failed practice had the likelihood to result in the inability of staff to ascertain food appropriateness for patients' diet orders.

Findings:

CURRENT DIET MANUAL

Observation showed use of a diet manual that was not current. Specifically:

On 07/02/25 at 12:57 PM, in the hospital's Director of Quality Management office, Staff B was observed looking at page 16 of the [name omitted] Diet Manual for Long Term Care Residents 2014 Revision to answer surveyor questions related to a dysphagia 2 diet.

Review of the document titled "[name omitted] Diet Manual for Long Term Care Residents 2014 Revision" showed it was signed by the administrator and dietary designee for the contracted dietary service on 02/01/25 and was provided to the surveyor by the contracted dietary service dietary designee.

ACCESS TO DIET MANUAL

The OK Nutrition Manual 2021 edition was provided to the surveyor on 07/02/25 at approximately 2:53 PM by Staff G as the hospital's diet manual.

On 07/02/25 at approximately 2:53 PM, Staff G stated:

1. The hospital staff do not have access to the diet manual.
2. There was no online resource for staff.
3. Staff G told hospital staff to call Staff G if there were questions whether a patient's food was accurate for the diet order.
4. Staff G had several diet manuals and one at home, but they used OK Nutrition Manual 2021 edition for the hospital.