Failure to Supervise Resident with Dysphagia Leads to Fatal Choking Incident
Summary
The facility failed to provide necessary supervision and assistance with Activities of Daily Living (ADL) care during meals for a resident diagnosed with dysphagia, which ultimately led to the resident's death by choking on a sandwich. The resident, a male with a complex medical history including cerebral palsy, functional quadriplegia, and dysphagia, required total dependence for ADL care and was non-verbal. Despite these needs, the resident was left unsupervised with a meal for 32 minutes, contrary to the prescribed one-on-one assistance during meals to prevent choking or aspiration. The resident's care plan was not updated to reflect the need for one-on-one assistance during meals, despite clear indications from the Speech Therapy Transitional Evaluation and Plan of Treatment that such supervision was necessary. The facility's policies on ADL and meal assistance were not adhered to, as the resident was left to consume a meal independently without the required supervision. This oversight was compounded by a lack of communication and coordination among staff, as evidenced by the CNA's decision to leave the resident's meal tray in the room without ensuring the resident was fed. Interviews with facility staff revealed a breakdown in the implementation of care plans and supervision protocols. The CNA assigned to feed the resident did not complete the task due to shift timing issues, and the subsequent CNA did not arrive in time to prevent the incident. The facility's Director of Nursing acknowledged gaps in the care planning process, citing frequent changes in ownership and leadership as contributing factors to the oversight. The failure to provide adequate supervision and assistance during meals directly resulted in the resident's death by choking.
Removal Plan
- The Regional Director of Operations and the Administrator reviewed the dining assistance policies to ensure alliance with CMS/State regulation.
- The Administrator, DON, and the Regional Director of Clinical Operation conducted mandatory retraining for nurses on supervision of ADL care including feeding/dining assistance assignments.
- The DON and/or Administrator retrained nursing staff that ADL care/meal assistance must continue uninterrupted and cannot be halted or delayed due to a shift change.
- The Administrator and DON assessed staffing levels during meal service to ensure adequate assistance.
- An emergency Quality Assurance and Performance Improvement Ad Hoc meeting was conducted with the Administrator, DON, RDO, RDCO, and Medical Director to review the removal plan and root cause analysis.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to provide routine grooming and personal hygiene assistance for two dependent residents. One resident with dementia was observed with long, uneven fingernails and debris under the nails, while another resident with dementia reported bothersome chin whiskers that staff had not addressed despite repeated requests. Staff gave inconsistent accounts of nail care and shaving practices, although the DON stated daily shaving was standard care for both males and females and that nail care was expected on shower days.
Failure to provide grooming assistance: A resident with an ADL self-care deficit related to weakness, limited mobility, confusion, a compression fracture, and a hx of falls was observed with hair extending beyond his ears while resting in bed. He stated he wanted a haircut and that staff had never offered one, and the DON said there was no written record showing the resident had been receiving or refusing haircuts. The facility policy required ADL care, including grooming, based on the individual care plan.
Failure to provide timely assistance and required ADL care: A resident’s call light was left unanswered for 23 minutes and another for 18 minutes, both beyond the facility’s stated response time. Other residents did not receive ordered positioning or incontinent care as documented; one resident with diabetes, AFib, and skin damage was observed without the required wedge or with it placed incorrectly, and another resident with dementia and total toileting dependence was found in bed with urine-soaked linens and no documented bowel/bladder care for most of the day.
Failure to Provide Shaving Assistance: A resident who was severely cognitively impaired and dependent on staff for ADLs was supposed to be shaved every morning and preferred to be clean shaven, but was repeatedly observed with whiskers on his face and neck over several days. The NA said the resident needed total assistance with shaving and was not shaved one morning because the electric razor was broken, while the RN stated staff should use the care guide/Kardex and report equipment issues when discovered; the DON confirmed the resident’s grooming preference and that staff should document the care actually provided.
Failure to assist a dependent resident with meals: A cognitively impaired resident with a hx of cerebral infarction, a mechanically altered diet, and orders for supervision/assistance with eating was observed sitting at lunch without staff cueing or feeding assistance for an extended period. Although the care plan and ADL documentation indicated she needed help and was dependent for eating, staff did not assist until a nurse aide later sat down to feed her, and the aide confirmed the resident typically required total assistance.
Failure to provide nail care for a resident with DM and vascular dementia. The resident had moderately impaired cognition, was totally dependent for toileting and personal hygiene, and his care plan directed staff to trim his nails as needed. Staff reported nail care was expected on bath days and when needed, but the resident’s fingernails were observed repeatedly to be long with brown substance under them, and records did not show that he refused nail care.
Failure to Provide Routine Grooming and Personal Hygiene Assistance
Penalty
Summary
The facility failed to ensure routine personal hygiene care was provided for 2 residents who were dependent on staff for assistance with activities of daily living. One resident, who had cognitive impairment, dementia diagnoses, and required maximal assistance with personal hygiene, toileting hygiene, and bathing, was observed with fingernails that were uneven, 1 to 1.5 cm long, and had black matter underneath. The resident was observed again with the same nail condition, and the DON stated residents' nails were supposed to be cut on shower day, with NAs expected to attempt nail care and report failures to nurses for reattempts. The second resident had moderate dementia, was dependent on staff for personal hygiene and toileting, and required maximal assistance with showering and bathing. The resident stated that whiskers on the chin bothered her and that she had told staff multiple times, but had never received a response or an offer to shave them. The resident was observed with light gray facial hair about 1/4 inch long across the bottom of the chin on multiple occasions, and the facial whiskers remained visible during later observation. Staff interviews showed inconsistent practice regarding nail care and shaving. One NA stated fingernails and toenails were checked on shower days and cut as needed, while another stated shaving depended on resident preference and that female residents were not typically asked about facial hair. An RN stated shaving was expected for every resident each morning and should be offered to female residents as well, especially if facial hair was noticed. The DON stated daily shaving was a standard of care for both males and females and that NAs were expected to offer it to every resident, with refusals documented and the care plan updated. The facility's ADL policy stated residents unable to perform ADLs would receive necessary services to maintain good grooming and personal hygiene, and the facial hair grooming policy stated the facility assisted residents with grooming facial hair as part of proper hygiene.
Failure to Provide Grooming Assistance
Penalty
Summary
The facility failed to ensure assistance with ADLs for grooming, specifically haircuts, for Resident #7, who was reviewed for ADL care. During an observation on 8/09/2026 at 10:16 AM, Resident #7 was resting in bed and his hair extended beyond his ears. When interviewed at that time, he stated that he would like to get a haircut and that staff had never offered to do that for him. His care plan dated 6/16/2026 documented an ADL self-care performance deficit related to weakness, limited mobility, confusion, compression fracture, and a history of falls. During an interview on 8/11/2026 at 9:30 AM, the DON stated that the facility did not have anything in writing showing that Resident #7 had been receiving or refusing haircuts. The facility policy stated that the facility shall provide care and services for ADLs as needed based on the individual care plan, including hygiene, bathing, dressing, grooming, and oral care.
Failure to Provide Timely Assistance and Required ADL Care
Penalty
Summary
The facility failed to provide necessary care and services for residents who were unable to complete activities of daily living independently. Facility policy stated that residents unable to carry out ADLs independently would receive services necessary to maintain good nutrition, grooming, and personal and oral hygiene, and that call lights should be answered as soon as possible, but no later than 5 minutes. During observation, Resident R3’s call light was illuminated for 23 minutes before being answered, and the resident stated she needed to be changed. During another observation, Resident R124’s call light remained illuminated for 18 minutes before a nurse aide entered the room and assisted the resident. The Nursing Home Administrator and DON were informed of the delayed response times and confirmed they would review call bell response with staff. The facility also failed to provide ordered positioning and incontinent care for other residents. Resident R62 had diagnoses including diabetes and atrial fibrillation, required substantial/maximal assistance to roll in bed, had moisture associated skin damage at the base of the spine, and had a physician order for a wedge in bed at all times. Observations showed the resident lying on the back without a wedge present, and later with the wedge placed under the fitted sheet at the same level as the head rather than at torso level as confirmed by the wound nurse. Resident R128 had diagnoses including diabetes, chronic kidney disease, and dementia, was dependent on staff for toileting hygiene, and was always incontinent of urine and frequently incontinent of stool. The resident was observed in bed with a strong odor of urine and wet, saturated linens and blanket; although staff stated the resident sometimes refused care, the record did not document a refusal, and the point-of-care record showed no bowel or bladder care documented from early morning until late evening that day.
Failure to Provide Ordered Shaving Assistance
Penalty
Summary
The facility failed to provide assistance with activities of daily living for a resident who was dependent on staff for care. The resident’s quarterly MDS indicated severe cognitive impairment and dependence on staff for ADLs, and diagnoses included paraplegia, dementia, anxiety, major depression, and multiple sclerosis. The care plan identified a need for assistance with personal hygiene and noted the resident preferred to be clean shaven. During observations, the resident’s face and neck were repeatedly noted to have black and gray whiskers, including on multiple days and at different times. When asked, the resident indicated that the whiskers bothered him and that he preferred to be shaved every day. A NA stated the resident required total assistance with shaving, usually did not refuse, and preferred to be shaved, but was not shaved one morning because the electric razor was broken. An LPN stated she had just learned that day the razor was broken, and an RN stated staff used care guides and the Kardex to identify care needs, that the resident was to be shaved every morning, and that staff should report equipment issues when discovered. The RN also stated documentation showing the resident had been shaved on one date did not appear consistent with observations and would be investigated as possible inaccurate documentation. The DON confirmed the resident preferred to be clean shaven and that staff should document the care actually provided.
Failure to Assist Dependent Resident With Meals
Penalty
Summary
The facility failed to provide dependent residents the necessary services to maintain nutritional status for one resident who was unable to carry out activities of daily living. Resident 51 was cognitively impaired, had a diagnosis of cerebral infarction, required substantial/maximum assistance with eating, and was ordered a mechanically altered diet with nectar consistency liquids and supervision and assistance with meals. Her care plan directed staff to cue and prompt her at mealtimes so she could feed herself as much as possible, with staff assisting as needed. During observation in the dining room, the resident was served lunch and her food was uncovered, but she remained seated with her eyes closed and did not attempt to feed herself. For more than 40 minutes, no staff attempted to assist her with the meal or cue her to eat, until a nurse aide finally sat down to feed her. The nurse aide stated the resident usually needed assistance with feeding and was receptive to food once feeding began. Review of ADL documentation showed the resident was dependent on staff for eating assistance on prior meals, and the lunch meal documentation later reflected that she required total assistance rather than set-up assistance. The Nursing Home Administrator confirmed staff should have assisted her to eat.
Failure to Provide Nail Care for a Resident with Diabetes
Penalty
Summary
The facility failed to ensure Resident 39 received assistance with ADLs for nail care. R39 had diagnoses of diabetes mellitus and vascular dementia, a BIMS score of 8 indicating moderately impaired cognition, and was documented as totally dependent for toileting and personal hygiene. His care plan instructed nursing staff to trim his nails as needed, and facility staff stated that nail care was expected on bath days and when needed. However, the resident’s fingernails were observed on multiple occasions to be long with a brown substance under all fingernails. Record review showed R39 was scheduled for showers on Sunday, Wednesday, and Friday mornings, and hospice aide documentation from 06/03/2026 through 07/03/2026 showed no care refusals. EMR task review from 07/03/2026 through 08/03/2026 documented one shower refusal, but there was no documentation that he refused nail care. Staff interviews indicated the nurse was responsible for trimming his nails because he was diabetic, and that nail cleaning should occur during showers or as needed. One consultant staff member reported she had not been allowed to trim his fingernails and had verbally told the nurse when they needed trimming, while the nurse stated she was unsure when the nails were last trimmed.
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