Failure to Follow Care Plan Results in Resident Choking and Death
Summary
A deficiency occurred when a resident with a history of dysphagia following cerebral infarction, oropharyngeal phase dysphagia, cerebrovascular disease, adult failure to thrive, and severe cognitive impairment was not provided care in accordance with their comprehensive care plan. The resident's care plan and physician orders specified a mechanically altered, pureed diet with thin liquids due to their swallowing difficulties and risk of choking. Despite these documented dietary restrictions, the resident was given a sandwich by a Certified Nursing Assistant (CNA), which was not consistent with the prescribed diet. The incident was observed when the resident, while sitting in a wheelchair at the nursing station, began choking on undigested food. Food was seen falling from the resident's mouth, and the resident was struggling to breathe. Immediate interventions, including the Heimlich maneuver and a mouth sweep, were attempted by an LPN but were unsuccessful. Cardiopulmonary resuscitation (CPR) was initiated, and emergency services were called. The resident eventually started breathing again and was transported to the hospital by EMS. Following the event, it was determined that the resident was admitted to a hospice facility after hospital discharge and subsequently expired. The facility's failure to implement the resident's care plan and provide the appropriate diet as ordered directly led to the choking incident and the resident's transfer to the hospital, hospice admission, and eventual death. The survey identified this as noncompliance with federal requirements for comprehensive care planning and quality of care.
Removal Plan
- The facility's Modified Texture of Food Policy, Care Plan Policy, and Resident Food Preferences Policy were reviewed and staff in-service education was initiated. All policies were reviewed with 100% staff except those on Leave of Absence and Family Medical Leave Act.
- An Ad Hoc QAPI meeting was held with key facility leadership and staff to review the IJ Removal Plan. The Care Plan policy was reviewed with no changes. A Daily Diet Verification Audit was performed for 100% of current residents to ensure meal tray cards matched diet orders, Kardex, and care plans.
- No staff worked until they had completed the in-service education. Part-time, PRN, and contracted staff will be in-serviced and educated on the relevant policies before being allowed to work.
- All newly hired staff will be in-serviced on their first day of hire during orientation, annually, and quarterly. Individuals will not work until they have received this in-service/training. All residents' care plans were reviewed and updated to reflect appropriate diet orders.
- The facility implemented interventions to minimize environmental risks and hazards, including Daily Diet Verification Audit, Snack Distribution Audit, and Meal Tray Observation Audit for 100% of current residents. Education was provided to all staff regarding relevant policies and reporting procedures.
- New interventions will be monitored by the DON for effectiveness using audit tools. If a problem is identified, it will be addressed by the Food Service Director, Administrator, DON, and Medical Director, with possible Ad Hoc QAPI meetings and corrective action if necessary.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with multiple diagnoses, including diabetes and COPD, had a physician’s order for apixaban 5 mg twice daily and a corresponding care plan directing staff to administer the anticoagulant as ordered and to monitor and document specific side effects such as abnormal bleeding, bruising, black stools, pink-tinged urine, leg pain or swelling, nausea, vomiting, and sudden chest pain or shortness of breath. Record review showed no documentation that staff monitored for these anticoagulant side effects as required by the care plan, and the CNO confirmed that monitoring for the anticoagulant was not in place despite the expectation that it should have been.
A resident with paraplegia and moderate cognitive impairment, dependent on staff for transfers and using a manual wheelchair, was observed alone in a courtyard sitting in direct sunlight without a drink, contrary to his care plan interventions. The resident reported being routinely left outside unattended, without a way to call staff, and not being offered sunscreen when outside. The care plan called for encouraging fluids, supplying and assisting with sunscreen, and offering assistance in and out of doors, but an RN acknowledged there was no monitoring system or set check times while the resident was outside and that there was no physician order for sunscreen available to offer.
A resident with dementia, anxiety, repeated falls, and dependence on staff for ADLs did not have dentures and glasses addressed in the comprehensive care plan, despite documentation of very impaired cognition, communication difficulties, poor intake with chewing problems, and inconsistent eye contact. Existing nutrition and ADL care plans directed staff to assist with eating, dressing, personal care, and grooming but omitted any mention of dentures, glasses, or the resident’s preferences and responses to using them. Observations found the resident seated in a Broda chair without dentures or glasses, while staff reported these items were in the room and that the resident’s willingness to use them varied, and nursing leadership acknowledged the care plan should have reflected their use and refusals.
A resident with leukemia, dementia, anxiety, and depression was observed in bed using a transfer pole and a 1/4 bed rail, but these assistive devices were not documented in the resident’s comprehensive care plan. Record review confirmed the absence of any care plan addressing the transfer pole or 1/4 bed rail, and the CRN acknowledged that a care plan for these devices should have been in place.
A resident with multiple diagnoses, including chronic PTSD and joint replacement surgery aftercare, did not have their PTSD addressed in the comprehensive person-centered care plan, despite facility policy requiring that all individual conditions and needs be reflected with measurable goals and interventions. Review of the care plan showed no focus, interventions, or tasks related to PTSD, and the CNO acknowledged that the PTSD diagnosis should have been included in the care plan but was not.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Implement Anticoagulant Monitoring Interventions in Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s implementation of a comprehensive, person-centered care plan related to anticoagulant therapy. The State Operations Manual Appendix PP requires that comprehensive care plans include specific interventions to enable residents to meet objectives, and the facility’s own policy states that care plans must include measurable goals, appropriate interventions, and realistic timeframes. Resident #2, admitted and later readmitted with multiple diagnoses including diabetes and COPD, had a physician’s order dated 12/27/25 for apixaban 5 mg by mouth twice daily. In response, the facility initiated a care plan on 12/27/25 documenting that the resident was on anticoagulant therapy and directing staff to administer the medication as ordered and to monitor and document effectiveness and potential side effects, including abnormal bleeding or bruising, black stools, pink-tinged urine, leg pain or swelling, nausea and vomiting, and sudden onset of chest pain or shortness of breath, with instructions to notify the physician as indicated. Record review showed that Resident #2’s documentation did not include evidence that staff were monitoring for the side effects of the anticoagulant as outlined in the care plan. Despite the care plan’s specific directive to monitor and document for these potential adverse effects, there was no corresponding monitoring documentation in the resident’s records. During an interview on 4/14/26 at 10:15 AM, the CNO confirmed that Resident #2 did not have monitoring in place for the anticoagulant and stated that there should have been a monitor. This lack of documented monitoring demonstrated that the facility failed to ensure that the comprehensive, person-centered care plan interventions for anticoagulant therapy were implemented for this resident.
Failure to Implement Care Plan for Resident Outside in Courtyard
Penalty
Summary
The deficiency involves the facility’s failure to implement an existing care plan for a resident who liked to go outside in an unsecured courtyard area. During an observation, the resident was seen alone in his wheelchair in direct sunlight without a drink. In an interview shortly afterward, the resident reported that staff always left him outside unattended, that he had no way to notify staff when he was ready to return indoors, that he had not been offered sunscreen, and that he was ready to go back inside. The resident’s diagnoses included paraplegia, and his most recent Quarterly MDS showed he was moderately cognitively impaired, dependent on staff for transfers, and used a manual wheelchair for mobility. The resident’s care plan, in place since 2018, documented that he liked to go outside in an unsecured area, was not considered an elopement risk, had a BIMS score of 13, and had been educated to notify staff when outside and to remain on the sidewalk. Care plan interventions included encouraging the resident to have a drink of choice when outside, supplying sunscreen and assisting with its application when appropriate, and offering assistance in and out of doors. An RN stated there was no monitoring system or set time intervals for checking on the resident while he was outside unattended, and that staff often only told him a time limit for being outside. The RN also noted the resident was not wearing sunscreen because he often refused it previously, and the physician’s orders did not include an order for sunscreen to be available to offer. The facility’s Comprehensive Care Plan policy required periodic review and revision of care plan problems, goals, and interventions following each OBRA MDS assessment.
Failure to Include Dentures and Glasses in Comprehensive Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to develop a comprehensive, individualized care plan addressing a resident’s dentures and glasses. The resident had dementia with severely impaired cognition, anxiety disorder, repeated falls, and required staff assistance with oral care, toileting, bathing, dressing, footwear, and personal hygiene. The MDS and CAAs documented that the resident was very cognitively impaired, needed staff to anticipate his needs, and had communication difficulties, including missing or not understanding what was said. Existing care plans for nutrition and ADLs directed staff to provide verbal cues and assistance with eating, dressing, personal care, and grooming, but did not identify that the resident used dentures or glasses, nor did they include his preferences or responses to using these items. Facility records showed that the resident’s bottom dentures had previously broken after he placed them in his overall pocket and they fell out when staff removed his overalls. A dietitian note documented that the resident had dentures and reported difficulty chewing tougher meats, and a social services note documented that he did not always exhibit good eye contact during conversation. During observation, the resident was seated in a Broda chair near the television without his dentures or glasses and appeared restless and fidgeting. Social services staff confirmed that the dentures and glasses were in the resident’s room and that whether he wore them depended on his mood. Administrative nursing staff acknowledged that the care plan should have reflected that the resident had dentures and glasses and that he sometimes refused to wear them, but this information was not included in the care plan despite the facility’s use of the RAI process to develop individualized care plans.
Care Plan Omission for Resident Assistive Bed Devices
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure a resident’s comprehensive, person-centered care plan accurately reflected the use of assistive devices. One resident, admitted with multiple diagnoses including leukemia, dementia, anxiety, and depression, was observed in bed with a transfer pole on the left side of the bed and a 1/4 bed rail on the right side. Review of the resident’s care plan showed no documentation of the transfer pole or the 1/4 bed rail. In a subsequent interview, the CRN confirmed that there was no care plan implemented related to the 1/4 bed rail and transfer pole and acknowledged that there should have been. This lack of documentation and care planning for the assistive devices constituted the cited failure and had the potential to result in unmet care needs and increased risk to resident safety, as noted in the survey findings.
Failure to Care Plan for Resident’s PTSD Diagnosis
Penalty
Summary
Surveyors found that the facility failed to develop and implement a comprehensive, person-centered care plan addressing a resident’s diagnosed Post-Traumatic Stress Disorder (PTSD). The facility’s policy on Comprehensive Care Plan and Conferences, dated 9/3/25, required that care plans reflect residents’ individual conditions, risks, needs, behaviors, cultural values, and preferences, and include measurable goals, appropriate interventions, and realistic timeframes. Resident #13 was initially admitted and later readmitted with multiple diagnoses, including chronic PTSD and joint replacement surgery aftercare, and the medical record dated 3/3/26 documented a diagnosis of chronic PTSD. However, on 3/31/26 at 2:09 PM, review of the resident’s care plan showed no focus, interventions, or tasks addressing the PTSD diagnosis. On 4/1/26 at 12:47 PM, the CNO confirmed that the resident’s PTSD diagnosis should have been care planned and had not been, demonstrating noncompliance with the facility’s care planning policy.
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