Failure to Provide Meal Assistance Leads to Choking Incidents
Penalty
Summary
The facility failed to provide necessary meal tray setup assistance for a resident, identified as Resident 76, who was unable to independently manage their meals due to severe cognitive impairment. The resident, diagnosed with dementia and anxiety, was admitted with a regular diet order and required supervision or touching assistance for feeding. Despite this, the resident's care plan did not adequately address the extent of meal assistance required, specifically the need for food to be cut into bite-sized pieces to ensure safe swallowing. On two separate occasions, the resident experienced choking incidents while consuming meals, necessitating the use of a LifeVac device to dislodge large pieces of food. The first incident involved a piece of chicken the size of a fifty-cent coin, and the second involved a large piece of meat. These incidents occurred because the resident was not provided with the necessary setup assistance to ensure their food was appropriately prepared for safe consumption. The facility's failure to cut the resident's food into manageable pieces directly contributed to these choking events. Interviews with facility staff, including the Director of Nursing and the foodservice director, confirmed that the resident required tray setup assistance, which was not provided. The facility's policies on meal assistance and the use of the LifeVac device were reviewed, highlighting the lack of adherence to established protocols. The deficiency was further evidenced by the absence of documented tray setup assistance and the serving of whole chicken breasts to the resident, contrary to their needs.
Plan Of Correction
Resident 76's care plan has been reviewed and updated to reflect the extent of meal assistance the resident requires for meals. Residents with documented need for meal tray set-up assistance will have care plans reviewed by The Clinical Care Coordinators and updated to ensure the appropriate level of assistance has been developed, documented, and implemented to meet the individual needs of the residents. The Clinical RAI Specialist will provide re-education to the Licensed nursing staff on how to develop and implement a care plan that addresses the extent of meal assistance the resident requires. The Director of Nursing or designee will re-educate the nursing staff on meal tray set-up assistance to ensure each resident's individual level of assistance is met. Clinical Care Coordinator or designee will perform random audits weekly for 4 weeks and then monthly for 2 months to verify resident with need for meal tray set-up has a care plan reflecting the extent of meal assistance needed. The Director of Nursing or designee will perform random audits weekly for 4 weeks and then monthly for 2 months to verify meal tray set-up is being completed as required for the individual residents. Audits will be submitted to the monthly QA committee meeting for review and any further recommendations for 3 months.