Inadequate Investigation of Choking Incident
Penalty
Summary
The facility failed to thoroughly investigate an incident involving a resident who experienced a choking episode that led to hospitalization. The resident, who had moderately impaired cognition and was on a mechanically altered diet, choked on a large piece of chicken, which was removed at the hospital. The facility's investigation did not include documented evidence such as staff statements or verification of the food consistency provided to the resident, as required by their policies. The investigation summary lacked confirmation that the resident received the correct diet consistency, and staff statements did not provide details about the meal served. The Director of Nursing, who was not in position at the time of the incident, acknowledged that the investigation should have included verification of dietary orders to ensure resident safety. The facility's failure to conduct a thorough investigation violated their policies on incident reporting and aspiration precautions.
Plan Of Correction
Plan of Correction: Approved February 12, 2025 1. The Director of Nursing and Administrator have reviewed the incident and accident policy. The policy has been revised to rule out neglect, abuse and mistreatment within 72 hours of incident. Completed: 1/31/2025 2. All clinical staff will be educated on the incident and accident policy. Date: 2/28/2025 3. The lead investigator will interview all staff whom worked to determine if abuse, neglect, or mistreatment is involved. If determined within 72 hours, the staff will be suspended pending investigation. 4. Review of aspiration protocol was completed by the Administrator, Director of Nursing, Medical Director, and speech pathologist. Reeducation will be held with existing clinical staff on facility aspiration protocol. Completion date: 2/28/2025 5. 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 choking incident; dietary order was changed (MONTH) 21, 2024 to reflect speech language pathologist recommendation. Completed: 8/21/2024 6. Aspiration precautions: residents will receive tray when C.N.A and/or licensed clinical staff are able to visualize consumption of meal. If the tray or meal ticket are incorrect, the tray will be withheld until staff notify the kitchen immediately for correction and inform supervisor of the error. Completion date: on-going 7. Findings will be reported to the Quality Assurance team on a monthly basis for 3 months, then quarterly. Responsible party: Director of Nursing