Improper Feeding of a Community Living Center Patient Who Died and Inadequate Review of the Patient’s Care, VA New York Harbor Healthcare System in Queens

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate an allegation that improper feeding by a registered nurse (RN) at the New York Harbor Health Care System’s Community Living Center (CLC) contributed to the death of a patient. The OIG identified concerns related to inaccurate electronic health record (EHR) documentation and an inadequate facility review of the patient’s care. The OIG substantiated that improper feeding during lunch by a CLC RN contributed to the death of a patient. Approximately five hours after being fed lunch when the patient was intubated, a piece of chicken was removed from the patient’s airway. A code team physician documented two EHR notes indicating a dimension of the chicken as .8 cm in one note and 8 cm in the second note. The OIG was unable to determine the exact size of the chicken but based on the information available, concluded that the chicken did not have a dimension of 8 cm but was larger than an appropriate size to feed to the patient. CLC nursing staff did not include accurate meal consumption documentation on the day at issue. Two staff members entered an EHR note which contained differing amounts of food the patient ate at breakfast. There was no documentation the patient ate lunch. The OIG determined that facility leaders did not complete a comprehensive review of the event. The Cardiopulmonary Resuscitation Subcommittee completed an insufficient review of the code by not determining the accuracy of the EHR documentation. No staff member submitted an incident report of the adverse clinical outcome. A clinical disclosure was completed but not an institutional disclosure. The OIG made seven recommendations to the Facility Director related to nursing competencies and training, feeding documentation, review of the patient’s care, committee oversight, incident reports, and institutional disclosure.