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:
A resident with spinal cord disease, chronic pain, COPD, right-eye blindness, and a history of falls required one-person assist for transfers and ADL. She repeatedly used her call bell and yelled for help after breakfast because she wanted to get up, shower, and attend BINGO, but staff did not assist her out of bed until mid-afternoon. Staff said the assigned NA got behind with showers and other duties, and an RN acknowledged the resident had voiced concern that no one had helped her up when she requested it.
A resident who was dependent on staff for toileting and transfers was left in bed in an incontinent brief for an extended period after asking for help, crying that staff told her to pee her pants and that this happened often. Staff later provided incontinent care and used a mechanical lift for transfer. Another resident who needed supervision and assistance with meals sat with food in front of her for 45 minutes before staff helped her eat, while staff reported the dining room was short-staffed and the resident needed more meal assistance.
A resident with severe cognitive impairment, Alzheimer’s disease, and dependence on staff for oral hygiene did not receive routine tooth brushing during morning ADL care. Nursing assistants helped with bathing, dressing, perineal care, grooming, and transfer, but oral care was not offered or completed. A family member said staff did not routinely brush the resident’s teeth, and the RN stated oral care and brushing were expected with morning and evening cares per facility policy.
Failure to provide routine grooming: a resident who was dependent on staff for ADLs and preferred no facial hair was observed with visible facial hair on multiple occasions, and records for baths/showers did not show shaving was offered, completed, or refused. The resident stated staff did not ask about shaving, and RN and DON interviews confirmed shaving should be offered as part of grooming and documented if refused.
Failure to provide timely nail care for three residents was identified during observation, interview, and record review. Two residents with significant functional dependence had fingernails that were about 1/2 inch long, thick, and yellow, and one resident with DM and limited ability to bend had toenails about 1/2 inch long. Staff interviews showed that overgrown nails should be reported and that nail trimming was part of resident care, while the DON stated there was no reason the nails had not been cut.
Two residents who depended on staff for personal hygiene were left with unwanted facial hair despite facility policy stating grooming includes shaving and removal of facial hair. Staff confirmed CNAs were responsible for addressing facial hair during shower time, and both residents were observed with chin hairs; one resident with severe cognitive impairment said she wanted them shaved, and the other said the hair bothered her and made her feel like an odd ball.
Failure to Assist Resident With Requested Transfer and Morning Care
Penalty
Summary
The facility failed to assist a resident who required staff help with transfers out of bed when she requested it. Resident #8 was admitted with diagnoses including disease of the spinal cord, chronic pain, COPD with difficulty breathing, left hand contracture, and a history of falling. Her MDS indicated intact cognition, impairment on one side of the upper extremity, and the need for partial/moderate assistance with bed mobility and chair transfers, as well as substantial/maximal assistance with sit-to-stand. Her care plan also identified that she had impaired vision due to blindness in the right eye and required one-person assistance with transfers, with staff directed to assist her with all ADL she could not complete independently. On the day in question, Resident #8 stated she wanted to get up early, at least by 10:00 AM, and was unable to transfer independently. She reported that after breakfast she used her call bell repeatedly and yelled for staff because she wanted to get up, shower, and attend BINGO, but she was not assisted out of bed until about 2:45 PM. She stated that when staff finally came to her room, she was told they were running behind, and she said it hurt her feelings that she had to repeatedly request help. Staff interviews confirmed that Resident #8 was a one-person assist with a stand/pivot transfer and that she usually stayed in bed except for BINGO and showers. NA #1, who was new to the hall and assigned to Resident #8’s area, stated she got behind because she did not know the residents well, had two showers to provide, and was also assigned to assist in the dining room during lunch. Nurse #2 acknowledged that Resident #8 said before lunch that she wanted to go to BINGO and was concerned no one had helped her out of bed, but she did not assist because she was finishing medication pass. The Nurse Supervisor stated BINGO was scheduled for 2:30 PM and that no one had told her Resident #8 had not been assisted out of bed; the DON and Administrator both stated that if Resident #8 asked for assistance, staff should have provided it when requested.
Delayed Toileting Assistance and Meal Supervision
Penalty
Summary
The facility failed to provide timely toileting assistance and transfer support for a resident who was dependent on staff for toileting and transfers, was frequently incontinent of bowel and bladder, and had diagnoses including non-traumatic spinal cord dysfunction, diabetes, and dementia. The resident’s MDS and care assessments identified the need for extensive assistance, including assistance of two for transfers and toileting, use of a full body mechanical lift, peri care after incontinent episodes, and toileting every three hours. During observation, the resident was found lying in bed in an incontinent brief, crying, and stating that staff told her to stay in bed and pee her pants so they could clean her up there. The resident stated this happened all the time and that staff shut off her call light just about every day. The resident remained wet and in bed for an extended period before staff returned to provide care. A nursing assistant later entered, acknowledged the resident was wet, and performed incontinent care, including cleaning feces and urine from the resident’s skin, applying barrier cream, and putting on a clean brief and pants. After care was completed, the nursing assistant had to leave and return with another staff member to complete the transfer using a ceiling lift before the resident was taken to the dining room for lunch. Staff interviews confirmed the resident should not have had to wait when she needed the bathroom and that timely toileting assistance was expected to prevent incontinence and skin breakdown. The facility also failed to provide timely supervision and assistance with eating for another resident who was identified as cognitively intact and independent with eating on the quarterly MDS, but whose nutritional assessment stated the resident normally ate 51-75% of most meals and was assisted with meals for optimal intake. During lunch observation, there was not enough staff in the dining room to assist residents, and at least two residents sat with food in front of them without eating or receiving help. The resident remained seated with a plate of food in front of her for 45 minutes before staff assisted her to eat. Staff interviews indicated the resident had begun to need more help with meals, had started pocketing food, and required supervision and cueing while eating. The DON stated residents who required supervision with eating should be watched closely and assisted in a timely fashion when they stopped eating or had not started eating.
Failure to Provide Routine Oral Care
Penalty
Summary
The facility failed to provide assistance with routine grooming cares, including oral care, for a resident who was dependent on staff for oral hygiene, personal hygiene, eating, and dressing. The resident had severe cognitive impairment with diagnoses including Alzheimer’s disease, anxiety, and depression. The care plan identified a self-care performance deficit related to Alzheimer’s disease and dementia, along with impaired balance and weakness, and specified that the resident required total assistance of one with oral care and had her own teeth in good condition. A family member stated staff did not routinely brush the resident’s teeth and believed flossing occurred only occasionally. During morning observation, nursing assistants assisted the resident with transfer, bathing, dressing, perineal care, grooming, and getting her ready for the day, but oral care was not offered or completed. One nursing assistant later verified he did not offer to complete oral care or brush the resident’s teeth and stated he was not used to morning cares after recently working evening shifts. Another nursing assistant stated his usual practice was to complete oral care in the evening. The RN stated oral care and brushing of teeth were expected with morning and evening cares, and the facility policy required residents with their own teeth to have them brushed every morning, every evening, and as needed.
Failure to Provide and Document Routine Shaving for a Dependent Resident
Penalty
Summary
The facility failed to ensure routine personal hygiene, specifically shaving, was completed for a resident who was dependent on staff for ADLs. The resident’s quarterly MDS dated 5/11/26 indicated intact cognition, no hallucinations, delusions, behaviors, or rejection of care, and dependence on staff for personal hygiene, toileting, showering, dressing, and mobility. The care plan identified a preference for no facial hair and directed staff to provide grooming on shower days and as needed, with the resident totally dependent on staff for personal hygiene and oral care. Review of progress notes from 5/1/26 through 6/3/26 showed no documentation of refusals or completion of shaving. Weekly skin/bath assessments on 5/22/26 and 5/29/26 documented bed baths, and the weekly bath audit on 5/27/26 documented a shower, but none of these records showed that facial shaving was offered or completed. During observation and interview, the resident was seen with approximately 1/4 inch facial hair and stated staff did not ask if she wanted to be shaved and that she found it embarrassing to have to ask. On a later observation, the resident still had facial hair and stated no staff had asked if she wanted it removed. RN-A and RN-D stated shaving should be offered when staff notice facial hair and that shaving is part of daily grooming, while the DON stated shaving should be offered with showers and as needed and documented if refused.
Failure to Provide Timely Nail Care for Three Residents
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain grooming and personal care, specifically nail care, for three residents reviewed for ADL care. Resident #88 had a history of CVA, lack of coordination, muscle weakness, muscle spasm, anemia, and hand contractures, and was fully dependent for self-care. On observation, he was in bed with contracted hands and fingernails about 1/2 inch long on both hands that were thick and yellow; he nodded yes when asked if he wanted his nails trimmed. Resident #45 had Parkinsonism, other lack of coordination, weakness, localized edema, chronic pain, wrist drop, and muscle weakness, with severely impaired cognition and full dependence for self-care. On observation, he was in bed with tremors in both hands, and all fingernails on both hands were about 1/2 inch long and thick and yellow. He stated he wanted his nails trimmed and did not remember whether he had been offered nail trimming or when they were last trimmed. Resident #67 had acute respiratory failure with hypoxia, CHF, type 2 diabetes mellitus, muscle weakness, muscle wasting, and lack of coordination. Although his MDS reflected intact cognition and independence with personal hygiene, he stated he could trim his fingernails but could not bend down to trim his toenails. Observation showed toenails about 1/2 inch long on both feet, and he stated that he had neither requested nor been offered toenail trimming. Interviews with CNA staff and the nurse in charge showed awareness that nail care was part of resident care, that overgrown nails should be reported, and that nail trimming was important, while the DON stated there was no reason the residents' nails had not been cut.
Failure to Provide Grooming and Facial Hair Removal
Penalty
Summary
The facility failed to provide necessary ADL services for two sampled residents who were dependent on staff assistance for personal hygiene and grooming. Facility policy stated that grooming includes shaving and removal of facial hair, and staff interviews confirmed that CNAs were responsible for shaving residents as needed during shower time. Surveyors observed Resident #67 with several long, curly facial hairs on her chin during one observation, and the hairs were still present during a later observation and interview. Resident #67, who had diagnoses including weakness and vascular dementia and a BIMS score of 4 indicating severe cognitive impairment, stated she did not know the hairs were there and said she would like someone to shave them off. Resident #59 was also observed with scattered chin hairs approximately one-half to three-fourths of an inch long. She stated she could not recall staff asking whether she wanted them shaved, said it would be good if staff had a time and place to get it done, and explained that the facial hair bothered her and made her feel like an odd ball. She said she wanted the hair shaved, not plucked. CNA #1, LPN #2, and the ADON all confirmed that facial hair removal should be addressed during shower time and that leaving female residents with unwanted facial hair was a dignity issue. Resident #59 had diagnoses including unspecified dementia, weakness, and hypertensive heart and chronic kidney disease without heart failure, and her BIMS score was 08 with MDS documentation showing substantial/maximal assistance needed for personal hygiene.
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