Failure to Provide Correct Food Consistency Leads to Resident Harm
Penalty
Summary
The facility failed to ensure that food was prepared in a form designed to meet the needs of a resident, as recommended by the speech-language pathologist and physician's orders. Resident #4, who had moderately impaired cognition and was on a mechanically altered diet, experienced a choking incident after being served a meal. The resident was on a ground/soft diet with thin liquids, but during the incident, they choked on large pieces of chicken, which were later removed from their airway at the hospital. The facility's policy required meal trays to be checked for accuracy against the meal tray ticket, but it was unclear if this was done in this case. The incident resulted in actual harm to the resident, who was admitted to the emergency room in acute respiratory distress and required medical intervention to remove the obstruction. Interviews with facility staff revealed uncertainty about whether the correct food consistency was provided, as the resident's tray was removed before the choking incident was fully investigated. The staff member who served the tray was no longer at the facility, and the Director of Nursing at the time of the survey was not in the position when the incident occurred. The facility's failure to ensure the correct food consistency was served led to the resident's choking and subsequent hospitalization.
Plan Of Correction
Plan of Correction: Approved February 11, 2025 1. For resident #4 specifically, the facility has added an order to document when the resident refuses to get out of bed for meals. Resident #4 also worked with SLP upon returning to the facility from a choking incident; dietary order was changed (MONTH) 21, 2024, to reflect speech language pathologist recommendation. 2. All personnel involved in serving residents have been educated on the different consistencies in the facility, completed on (MONTH) 24, 2024. 3. Diet tech and dietician will interchangeably complete weekly meal audits. Findings will be presented to the quality assurance team. Any immediate findings will be corrected accordingly. Date: 3/16/2025 4. Speech Language Pathologist will review all menus and extensions to ensure that we are serving appropriate foods for all consistencies. Date: ongoing 5. The speech language pathologist initiated review of all residents in alignment with the MDS schedule starting (MONTH) 2024 and has continued to do. Completed: (MONTH) 2024. Responsible party: speech language pathologist 6. SLP will communicate any dietary changes to the clinical team utilizing a communication log and the dietary team via email. Nursing will be responsible to make changes in EHR, and the diet tech will reprint the dietary roster. 7. Findings from all audits will be presented to the Quality assurance team monthly for 3 months, then quarterly. Responsible party: dietary