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Based on review of video surveillance recording, interview and record review the facility failed to ensure a patient with physician ' s orders for 1:1 supervised feeding had supervision when his food tray was delivered to his room. Citing one patient (#1) named in a complaint.
Findings:
Patient # 1
Review of history and physical dated 7/30/10 revealed Patient # 1 was admitted to the rehabilitation facility on 7/30/10 with history of recent Cerebral Vascular Accident (CVA) with left sided weakness and dysphasia (difficulty swallowing).
Review of complaint narrative revealed allegations that Patient # 1 ' s mother found him on 8/1/10 in his room propped up in bed with his food tray. He was unattended and was unresponsive.
Review of physician ' s orders dated 7/30/10 revealed an order for fall and swallow precaution.
Further review of physician ' s orders dated 7/31/10 revealed an order for Mechanical soft diet with 1:1 feed supervision in a nurse group setting.
During an interview on 7/12/11 at 2:00 pm with Staff # 51, Chief Nursing Officer(CNO) she stated on the day of the incident(8/1/10) her investigation revealed a food tray was taken to the patient ' s room and left there by the Nurses Aide.
According to the CNO when the patient was found unresponsive the food tray was still in the room with about a quarter of the sandwich missing, there was crumbs on the front of his shirt and a mouth sweep by staff revealed a piece of bread in his mouth.
Review of the facility ' s video surveillance recording dated 8/1/10 revealed images of an aide (A) taking a food tray to the patient ' s room at 17:13 and exiting the room at 17:14
Further review of the surveillance record revealed at 17:37 nurses aide (A) Went into Patient # 1's room and came out immediately afterwards (less than a minute). The surveillance showed that nurses aide (A) Aide went back to the Patient ' s room at 17:50 and came out in less than a minute.
The surveillance review revealed the food tray was left in the patient ' s room for more than 30 minutes without staff supervision.

Review of the facility ' s policy/procedure dated May 2010. Titled "Dysphagia group Therapy/Meal Observation" described dysphagia group as: "Patients who have documented dysphagia and are able to benefit from skilled intervention by a therapist to learn strategies to protect the airway during the actual eating process."
The policy did not address staff responsibility to monitor and supervise the feeding of these patients.
During an interview on 7/13/11 at 1:45 pm with Staff # 50, Director of Quality she stated the policy was lacking in detail but will be rewritten. She further stated food trays should not be taken to a patient on supervised feeding unless a staff was present to assist with the meal.

Based on record review, and interview, the facility failed to develop a nursing care plan to reflect the care needs of a patient who had orders for supervised feeding and was on aspiration and swallow precautions. The patient was found unresponsive with an unsupervised food tray on his bedside table. Citing one patient (#1) identified in a complaint narrative.
Findings:
Patient # 1
Review of history and physical dated 7/30/10 revealed Patient # 1 was admitted to the rehabilitation facility on 7/30/10 with history of recent Cerebral Vascular Accident (CVA) with left sided weakness and dysphasia (difficulty swallowing).
Review of physician ' s orders dated 7/30/10 revealed an order for fall and swallow precaution.
Further review of physician ' s orders dated 7/31/10 revealed an order for Mechanical soft diet with 1:1 feed supervision in a group setting.
Physician ' s diet orders revised on 7/31/10 included nectar consistency liquids for the patient.
Review of Speech Therapist evaluation dated 7/31/10 revealed documentation for fall and aspiration precaution.
Review of a Nursing care plan dated 7/31/10 revealed the plan did not address the patient ' s need for swallow and aspiration precautions. There was no documented measures instituted to address the problem.
The plan did not document that the patient ' s need for supervised feedings with mechanical soft diet and nectar consistency liquids was implemented as ordered by the physician.
During an interview on 7/13/11 at 1:00 pm with Staff # 51, Chief Nursing Officer she stated she would in-service nursing staff on developing a care plan that addresses patient care needs.