F0689

J

Failure to Supervise NPO Resident Receiving Food and Fluids from Visitors

Spartanburg, South Carolina Survey Completed on 02-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that an NPO (nothing by mouth) resident was adequately supervised and protected from receiving food and fluids by mouth. The resident had an active physician’s order for NPO status and a care plan identifying high nutrition risk related to dysphagia and dependence on enteral nutrition for 100% of nutrient and energy needs, along with functional quadriplegia, history of subarachnoid hemorrhage, and epilepsy. The resident’s MDS indicated memory problems and use of a feeding tube as the nutritional approach. Despite these documented needs and restrictions, the resident was able to obtain and consume a cereal bar and water provided by visitors from a church group.

On the day of the incident, a CNA observed the resident in his room with a cereal bar in his mouth and removed it from his hand, then notified the nurse. Another LPN later observed a cereal bar in a blue wrapper and a Styrofoam cup, noting that the resident had some of the bar in his mouth and some in his hand, with about half of the bar already in his mouth and all of the water gone. The resident could not identify who had given him the items. Staff interviews and the medical director’s account indicated that the food and drink were given by an unknown church member or group visiting the facility, and that such missionary visits were common on weekends.

Following ingestion of the cereal bar and water, the resident developed symptoms including vomiting, sweating, clamminess, and gurgling, as documented in an Interact SBAR completed by an LPN. The SBAR noted that the event started with these symptoms after the resident ate a cereal bar from a church member, and recorded a blood pressure of 184/108. The NP reported being called by the nurse and informed that the NPO resident had received a cereal bar and water earlier that day and was now experiencing projectile vomiting and clamminess, and she ordered the resident to be sent to the hospital. Hospital records show the resident was admitted for vomiting, with a history of intracerebral hemorrhage, stroke, and schizophrenia, and was intubated for airway protection with suspected aspiration pneumonia, later requiring a tracheostomy. The state agency determined that the facility’s non-compliance with accident hazard and supervision requirements constituted Immediate Jeopardy at F689, effective as of an earlier date.

Removal Plan

• Assess the identified resident following the incident and implement provider orders.
• Discharge the resident to the hospital.
• Assess residents with nothing-by-mouth orders for change in condition, including changes in vital signs, respiratory distress, and gastrointestinal distress.
• Place a sign at the entrance of the facility instructing visitors and delivery drivers to consult with a nurse prior to delivering or providing food or drink to a resident.
• Post signs in rooms of residents with nothing-by-mouth orders identifying the resident as nothing by mouth and instructing staff/visitors to contact the nurse prior to providing any food or drink.
• Reeducate facility staff on the policy for food brought in from outside sources, including instructing staff to question visitors providing food/drink and to request visitors notify the nurse prior to providing food/drink to a resident.
• Complete audits of food distributed from outside sources to validate proper distribution.
• Hold an ad hoc QAPI meeting.
• Notify the Medical Director and provide updates on interventions completed.