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
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Multiple dependent residents did not receive scheduled showers, bed baths, or shaving as outlined in their care plans and the facility’s routine care policy. One resident recovering from spinal surgery missed numerous scheduled showers over several months. Another resident who relied on staff for self-care repeatedly requested shaving but was not shaved, and visible facial hair was observed after a recent shower. A resident with chronic respiratory failure and a tracheostomy, requiring substantial/maximal assist with personal hygiene, had no documented showers for an extended period and was observed with long facial hair, which staff acknowledged should be removed during bathing or as needed. A cognitively impaired resident with ESRD and CHF, scheduled for twice-weekly showers, had multiple undocumented or missed showers and reported not getting showers despite asking aides who said they lacked time. Another cognitively intact resident with hemiplegia and multiple comorbidities, also scheduled for twice-weekly showers, had several dates where documentation showed no shower/bath/bed bath provided or no entry at all, and she reported feeling unclean and unimportant when her showers were missed.
A cognitively intact resident with multiple medical conditions, including acute kidney failure and adult failure to thrive, was care planned as being at risk for self-care deficits and scheduled for twice-weekly showers on the night shift. Over a 30‑day period, documentation showed the resident received only two showers or bed baths, with no refusals recorded, despite her stated preference for at least twice-weekly bathing with hair washing. On multiple observations, her hair appeared greasy and unwashed, and she confirmed in interviews that she had not received showers or hair washing as preferred. The DON verified that residents should receive showers and hair care per their scheduled preferences and that staff must document this care, and facility policy required provision of ADL assistance to maintain grooming and personal hygiene.
The facility failed to provide timely meal assistance and scheduled showers to dependent residents. Several residents with dementia and other chronic conditions, who required staff help with eating, were seated in the dining room with uncovered trays placed in front of them and waited a prolonged period before CNAs began feeding them; staff did not offer to reheat cold food or provide alternatives when residents refused to eat. CNAs reported that only two staff assisted about a dozen residents in the dining room and that dependent residents routinely waited until all meals were served before receiving help, contrary to facility policy requiring prompt service and adequate staffing. In addition, a resident with dementia, mobility issues, and a history of stroke had a care plan for scheduled showers twice weekly, but documentation showed only one shower per week with no recorded refusals or evidence that the second scheduled shower was offered, and the administrator could not locate additional shower records.
The facility failed to provide and document scheduled showers for two dependent residents who required staff assistance with all ADLs, including bathing and hygiene. One resident, cognitively intact with hemiplegia and mental health diagnoses, was care planned for twice-weekly showers but reported only receiving about one per week, with records showing minimal or no documented showers since admission. Another resident with Alzheimer’s disease, malnutrition, and CKD was totally dependent for bathing and scheduled for twice-weekly showers, yet multiple scheduled shower days lacked documentation of care or refusals, and nurse notes did not show any refusals or reattempts. A family member questioned how this nonverbal resident could refuse showers, and the DON confirmed that showers were expected to be provided as care planned unless refusals were documented.
Two residents who were dependent on staff for ADLs did not receive appropriate nail care. One cognitively intact resident with multiple chronic conditions had long, jagged toenails and reported that staff did not provide toenail care, while a CNA confirmed the condition and was unsure if CNAs were allowed to trim toenails, despite facility documents assigning personal care duties to CNAs. Another resident with anoxic brain damage, severe cognitive impairment, and bilateral hand contractures had long, dirty fingernails with no documentation of nail care, and staff interviews revealed confusion over whether nail care was the responsibility of CNAs, hospice, or an outside service.
A resident with dementia, COPD, and bilateral upper arm amputations, who was cognitively intact and had orders for bilateral prosthetic devices and OT recommendations for stand-by assist and a scoop plate, was observed eating meals by bending over the plate and scooping food into the mouth rather than using utensils. On multiple observed breakfasts, the resident either pushed away loosely strapped utensils on the prostheses or stopped using a spoon and continued eating with the mouth, while staff either provided only brief verbal encouragement or did not intervene to assist or promote utensil use. Staff later reported that the resident preferred not to use utensils and needed daily encouragement, and the therapy director clarified that specific utensils were intended for use without prostheses, while the resident could use thin-handled utensils with the grabber hooks, indicating a failure to consistently assist with eating as outlined in the facility’s routine care policy.
Failure to Provide Scheduled Bathing and Shaving Assistance for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide scheduled and needed bathing and shaving assistance to multiple dependent residents in accordance with their care plans, preferences, and the facility’s routine care policy. One resident with spinal stenosis and recent L2–L5 decompression fixation fusion was care planned for substantial/maximal assistance with shower/bath and toileting hygiene and was scheduled for showers on Tuesdays and Fridays. Electronic documentation from early January through early April showed this resident did not receive a shower or bed bath on 11 identified scheduled days, and the DON confirmed these missed bathing events. Another resident with dysphagia and developmental issues, who required assistance with self-care and mobility, reported that she asked staff to shave her but they did not, which bothered her. During an observation following a recent shower, she stated she had not been shaved and that the hair "itched"; small gray hairs were visible on her chin. A CNA confirmed the presence of gray chin hairs and acknowledged the resident needed shaving, stating it would be addressed with the next scheduled shower. A further resident with chronic respiratory failure, tracheostomy status, heart failure, moderate intellectual disabilities, anxiety, depression, and PTSD required substantial/maximal assistance with personal hygiene and had a care plan for assistance with self-care, including personal hygiene. Her shower schedule called for showers on Monday and Thursday nights, with complete shaves for men and women. Review of documentation showed her last recorded shower/bath was nearly a year earlier, with no indication of additional personal hygiene or facial hair removal on that date. Observations on two separate days showed long white hairs on her chin and jaw line, which a CNA later confirmed, stating facial hair removal should occur with baths/showers or as needed. A resident with end stage renal disease, respiratory failure, hyperlipidemia, and congestive heart failure, who had impaired cognition and required partial/moderate assistance with bathing and personal hygiene, was scheduled for showers on Wednesdays and Saturdays. Review of shower documentation from admission through early April revealed no showers provided or refusals documented on at least ten scheduled shower days. In interviews, this resident reported not receiving scheduled showers, was unsure of his shower days, and stated he could use a good scrub down, adding that he had asked aides who told him they did not have time. A CNA explained that shower days appear on shower sheets and in the computer and that CNAs are supposed to document daily, with nurses checking the documentation; the DON verified the resident had not received showers per schedule or preference. Another resident with a fracture of the lower end of the left humerus, hemiplegia and hemiparesis after cerebral infarction, rheumatoid arthritis, hypertensive heart disease, urinary retention, and osteoarthritis was care planned as non–weight bearing to the left upper extremity and requiring substantial/maximal assistance with showering/bathing. Her electronic record showed she was scheduled for showers on Wednesdays and Saturdays. The shower task question "did the resident receive a shower/bath/bed bath?" was documented as "no" on three dates, indicating no shower/bath/bed bath was completed, and left unanswered on three additional dates. The DON confirmed that one missed shower was due to an outside appointment, that on two dates the "no" response meant no bathing of any type occurred, and that on three dates there was no documentation at all. The resident, who was cognitively intact, reported that missing showers made her feel unimportant compared to others and that she did not feel clean when her shower was missed. Facility policy on routine resident care stated that showers, tub baths, and shampoos are to be scheduled according to person-centered care or state guidelines, with additional showers given upon request, but the documented and observed care did not reflect consistent provision of scheduled bathing and shaving for these residents.
Plan Of Correction
1. Resident #5 received a shower by the STNA on 4/13/26. Resident #8 received a shower by the STNA on 4/8/26. Resident #9 received a shower and had their chin shaved by the STNA on 4/14/26. Resident #70 received a shower by the STNA on 4/13/26. Resident #76 received a shower and had their chin shaved by the STNA on 4/15/26. 2. Like residents are identified as residents who need assistance with showering and shaving. Utilizing the Shower Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, an audit of like residents will be completed by the Director of Nursing or designee to ensure that showers and resident shaving are completed. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses and STNA's on the Routine Resident Care Policy to include bathing and shaving residents. This education will be completed on or before 5/13/26. 4. Utilizing the Shower Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit of 4-6 residents weekly for four weeks, beginning 5/14/26 to ensure that showers and resident shaving are completed. Noncompliance found during audits will be addressed and assistance with showers and/or shaving provided. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Failure to Provide Scheduled Bathing and Hair Care for Dependent Resident
Penalty
Summary
The facility failed to provide timely bathing and hair washing assistance to a dependent resident in accordance with her care plan, stated preferences, and facility policy. The resident was admitted with diagnoses including acute kidney failure, adult failure to thrive, and depression, and an MDS assessment documented that she was cognitively intact. Her care plan identified a risk for self-care deficit with bathing, dressing, and feeding, with interventions to encourage participation in planning day-to-day care, evaluate her ability to perform self-care, minimize environmental stimuli, and provide ADL assistance as needed. The shower task list scheduled her to receive showers on the night shift on Sundays and Thursdays. However, review of shower documentation over a 30‑day period showed she received only two showers or bed baths, on 03/06/26 and 03/22/26, with no additional showers documented and no refusals recorded. During observations on two separate days, the resident’s hair appeared greasy and unwashed. In interviews conducted immediately following these observations, the resident stated she preferred to have a shower or bed bath at least twice a week with hair washing on those days, and she reported that she had not had her hair washed in weeks and was not receiving bathing at the frequency she preferred. A subsequent observation again showed her hair to be greasy and unwashed, and she confirmed she still had not received a shower or hair washing. The DON confirmed that residents were to receive showers and hair washing per their scheduled preferences and that staff were required to document this care in the medical record, and also confirmed that this resident had documentation of only two showers or bed baths in the 30‑day review period with no documented refusals. Facility policy stated that residents unable to carry out ADLs independently would receive services necessary to maintain grooming and personal hygiene, which was not met in this case.
Plan Of Correction
DON performed a physical, head-to-toe assessment/observation of Resident #8 on 03/26/2026. This assessment/observation revealed that no negative outcomes were experienced by Resident #8 regarding the missing shower documentation, greasy hair, or concern of lacking episodes of bathing/showering/hair care identified during Annual Survey. LNHA notified Resident #8's primary care provider on 03/26/2026 of missing shower documentation, greasy hair, and concerns for lacking episodes of bathing/showering/hair care identified during Annual Survey and that a physical, head-to-toe assessment/observation was completed, revealing no negative outcomes. Primary care provider acknowledged these findings and provided no new orders. Responsible Nurse reviewed Resident #8's bathing/shower schedule 04/09/26 to ensure shower/bed bath was scheduled appropriately. Resident previously moved rooms and bathing/shower scheduled was not updated, resulting in the above-described findings. Responsible Nurse adjusted Resident #8's bathing/shower schedule on 04/09/2026 to reflect her new room assignment with an associated bathing/shower schedule of every Tuesday and Saturday during dayshift (7a-7p). Resident #8 agreeable. DON added Resident #8's new bathing/shower schedule to Point-of-Care documentation on 04/09/2026 so that CNAs will be required to document bathing/showering episodes on Tuesdays, Saturdays, and as needed or requested. On or before 4/30/2026, DON/Designee will educate licensed and unlicensed nursing staff on the following: § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. §483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene; Also, on or before 04/30/2026, DON/Designee will educate licensed and unlicensed nursing personnel regarding the importance and requirement of providing bathing/showering per shower schedules. On or before 04/30/2026, DON/Designee will review residents' bathing/shower schedules to ensure residents are listed on shower schedules as appropriate. DON/Designee will complete weekly audits x5 medical records x4 weeks; then as determined by QAA. This audit will list the resident identifier (facility's identifier), when their bathing/shower episodes are scheduled, if the bathing/shower episode(s) have been documented as completed or at least offered per schedule, and if the resident appeared clean and well kept.
Failure to Provide Timely Meal Assistance and Scheduled Showers
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assistance with meals to dependent residents and to provide showers according to the established schedule. One resident with dementia, difficulty walking, chronic kidney disease, anxiety, and on hospice required substantial/maximal assistance for eating and was dependent for all other ADLs. Over the prior month, this resident’s meal intake declined from 26–50% to 0–25%, and then to not eating. On the observed morning, the resident was seated in the dining room at 8:53 A.M., breakfast trays arrived at 9:15 A.M., and her uncovered tray was placed in front of her at 9:32 A.M., but staff did not sit to assist her until 9:58 A.M. The CNA then offered food and drink, and the resident consumed about 10–20% of the meal; the CNA did not offer to reheat the food. Another resident with cerebral atherosclerosis, peripheral arterial disease with intermittent claudication, and adult failure to thrive had impaired cognition, required setup or clean-up assistance with eating, and was dependent for all other ADLs. The care plan for weight loss or malnutrition included encouragement to eat, recording meal intake, and providing supplements. On the observed morning, this resident’s uncovered breakfast tray was placed in front of him at 9:35 A.M., and the CNA did not begin assisting until 9:53 A.M. The resident took one bite and then did not want to eat more, and the CNA did not offer to warm the food or provide an alternative. A third resident with hypertension, diabetes, and Alzheimer’s disease had impaired cognition, was dependent for eating and all ADLs, and had a care plan requiring setup, cueing, reminders, and assistance with feeding. This resident’s uncovered meal was placed in front of her at 9:35 A.M., and the CNA did not assist until 9:53 A.M.; the CNA did not offer to warm the food. The resident ate toast with encouragement but refused further eggs after the first bite. Staff interviews confirmed that residents needing assistance with eating are brought to the dining room and must wait until aides finish serving meals on the unit, resulting in no set breakfast time other than around 9:30 A.M. and delays until about 10:00 A.M. before staff can sit to assist dependent residents. CNAs reported that only two staff are typically in the dining room to assist 13 residents at all meals, causing residents to wait and food to become cold. The facility’s Dining Room Service policy stated that meals will be served promptly to maintain adequate temperature and appearance and that adequate staff should be available to assist individuals who need help. Additionally, another resident with dementia, gait and mobility abnormalities, acute kidney failure, history of stroke, and cognitive communication deficit had a care plan indicating assistance with ADLs and a shower schedule on day shift Monday, Thursday, and as necessary. Review of shower documentation over several weeks showed only one shower per week on Thursdays, with no documentation of a second scheduled shower being offered or provided and no refusals recorded for the missed showers, despite the administrator confirming that all showers should be documented in the point-of-care records and being unable to locate additional documentation that showers were offered or provided per schedule.
Failure to Provide and Document Scheduled Showers for Dependent Residents
Penalty
Summary
The facility failed to provide scheduled showers and document bathing care for dependent residents as outlined in their care plans and facility policy. One resident with hemiplegia, tremors, anxiety disorder, and major depressive disorder was care planned and scheduled to receive showers on Mondays and Fridays and required assistance with all ADLs. Review of the shower schedule and shower sheets showed only a few showers documented over a multi-month period, and CNA Point of Care records showed no evidence of showers since admission. The resident reported she did not receive showers as scheduled, stating she was fortunate to receive one shower per week and that she was upset about not getting the two weekly showers planned. Another resident with Alzheimer’s disease, protein calorie malnutrition, major depressive disorder, and chronic kidney disease was care planned as totally or nearly dependent on staff for bathing, hygiene, and dressing, with showers scheduled twice weekly. Review of shower documentation revealed multiple missed shower dates with no evidence that showers were provided on those days. Nursing progress notes contained no documentation of shower refusals or attempts to provide showers at a later time. The resident’s daughter reported staff told her the resident refused showers, but she stated the resident does not speak and expressed confusion about how the resident could refuse. The DON confirmed the missing shower documentation for both residents and stated that showers are to be provided as care planned, requested, and as needed unless refusals are documented, as required by the facility’s ADL policy.
Failure to Provide Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate nail care for two residents who were dependent on staff for activities of daily living. One resident, admitted with multiple diagnoses including COPD, dysphagia following cerebral infarction, malnutrition, hypertension, anxiety, and depression, was cognitively intact and dependent on staff for putting on and taking off footwear. Observation showed this resident had long, jagged toenails, and the resident reported that staff did not provide toenail care. A CNA confirmed the poor condition of the toenails and expressed uncertainty about whether CNAs were permitted to trim toenails. The resident had previously declined podiatry care, and facility documents indicated that CNAs were responsible for personal care and that routine daily care was to be provided. The second resident had an admission diagnosis that included anoxic brain damage, COPD, dysphagia, bilateral hand contractures, ADHD, moderate protein-calorie malnutrition, psychoactive substance abuse, anxiety disorder, and cognitive communication deficit, with severely impaired cognition and dependence on staff for personal hygiene and bathing. The care plan identified self-care deficits related to anoxic brain injury and contractures, and noted the resident was dependent for personal hygiene. There was no documentation in the medical record indicating when this resident’s nails were cleaned or cut. Observations on multiple occasions revealed long fingernails on both hands, with a dark brown substance underneath, and the resident declined to open his contracted hand or accept assistance. Staff interviews showed confusion about responsibility for nail care, with a CNA and an RN suggesting an outside service or hospice might be responsible, while the DON stated that CNAs were responsible for nail care.
Failure to Provide Appropriate Self-Feeding Assistance for Resident With Prosthetic Arms
Penalty
Summary
The facility failed to provide appropriate assistance and accommodation for self-feeding to a resident with bilateral upper arm amputations who used prosthetic arms. The resident, admitted with diagnoses including dementia, traumatic amputation at both elbows, and COPD, was cognitively intact with a BIMS score of 14 and required staff setup assistance for eating per the MDS. Physician orders directed that bilateral upper arm prosthetic devices be applied before breakfast and removed after dinner, with skin checks each shift. OT notes from 12/03/25 to 02/06/26 documented discharge recommendations for self-feeding that included stand-by assist from staff and use of a scoop plate. During breakfast observations on two separate days, the resident was seen eating without appropriate use of utensils or assistive devices, despite the documented needs and therapy recommendations. On one morning, the resident sat in the dining room with bilateral prostheses and grabber hooks in place; red and white plastic utensils were loosely strapped to the prostheses. The resident pushed the utensils up out of the way and bent over the plate, scooping French toast into his mouth without using utensils, despite an activities assistant encouraging him to use the utensils. On another morning, the resident initially used a regular spoon to eat cereal but then put the spoon down and bent over the plate to eat scrambled eggs with his mouth, without staff coming to assist or encourage utensil use. The therapy director later clarified that the red and white utensils were intended for use when the prostheses were not on, and that the resident preferred thin-handled utensils that could be held with the grabber hooks. A CNA confirmed that the resident typically did not use utensils, preferred to scoop food with his mouth, and required daily encouragement to use a spoon or fork. The facility’s routine care policy included assisting residents with eating and hydration, but staff actions did not consistently reflect this for the resident.
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