Failure to Provide Adequate Supervision and Implement Care-Plan Interventions for Choking Risk
Penalty
Summary
The facility failed to ensure that a resident with a known history of dysphagia, intellectual disability, and behavioral issues received adequate supervision and implementation of care-planned interventions to prevent choking incidents. The resident had previously experienced a choking episode after grabbing and consuming a large amount of food before staff could intervene, requiring the Heimlich maneuver and suctioning. Physician orders and speech therapy assessments specified that the resident required one-on-one supervision during meals, cueing for small bites and sips, a slow eating rate, redirection to prevent wandering, and upright positioning during all oral intake. During survey observations, staff assigned to provide one-on-one supervision did not consistently offer the required cueing for small bites, slow eating, or ensure the resident maintained an upright position while eating. The staff member also left the resident unattended during meals, contrary to the care plan and physician orders. The resident was observed eating with her hands, taking large amounts of food at once, and falling asleep while chewing, all without adequate staff intervention or prompting. These actions were not in line with the interventions identified to address the resident's choking risk. Interviews with staff revealed a lack of understanding regarding the reasons for the resident's one-on-one supervision and the specific interventions required during meals. Some staff were unaware of the need for cueing and supervision to prevent choking, and the speech therapist and DON were not aware that the care plan was not being followed. Documentation and care plans indicated the necessity for these interventions, but they were not consistently implemented, resulting in a continued risk of choking for the resident.
Removal Plan
- Resident #45 was placed on one-on-one supervision to ensure continuous monitoring during mealtimes and to reduce the risk of choking. The resident will be reviewed by the interdisciplinary team (IDT) to determine appropriateness of remaining on one-on-one supervision.
- An audit of all nursing staff cardiopulmonary resuscitation (CPR) certifications, specifically including verification of Heimlich maneuver training, will be completed.
- The facility will have a minimum of one person who is CPR certified and Heimlich maneuver trained in the facility and observing meals at all times.
- All residents were screened utilizing the swallowing disorder section from their most recent minimum data set (MDS) assessment.
- For any residents identified as having swallowing difficulties, the IDT ensured care plans were reviewed and appropriate interventions were implemented. Communication will occur with staff by updating care plans and by updating Kardex (staff directive tool). The director of nursing (DON) or designee will perform education to all nursing staff.
- The DON or designee conducted in-service training on the Foreign Body Airway Obstruction policy for all currently scheduled facility and agency staff. Staff not present will receive education.
- The speech language therapist (SLP) or a designee who has been trained by the SLP, provided training to all nursing and agency staff regarding expectations when assigned as a one-on-one during meals, including not leaving the resident unattended, intervening if the resident begins to fall asleep, and implementing appropriate interventions if the resident exhibits unsafe eating behaviors. Staff not trained will be educated.
- The DON or designee educated nursing and agency staff on all relevant physician's orders related to Resident #45. Staff not in attendance will receive training.
- The DON or designee reviewed the care plan interventions for Resident #45 with all available nursing and agency staff. Staff not trained will be educated.