Failure to Implement Recommended Diet Following Choking Incident
Penalty
Summary
The facility failed to ensure that care and services were provided according to accepted standards of clinical practice for one resident following a significant choking incident. The resident, who had a history of esophageal obstruction and food impaction, was hospitalized after choking on a piece of beef stew. Upon discharge, the hospital recommended a clear liquid diet to be advanced to a mechanical soft diet, with instructions not to progress to solid foods until a follow-up with gastroenterology (GI) was completed. However, upon the resident's return to the facility, the physician's order and dietary communication did not reflect the recommended mechanically altered diet, and the resident continued to receive a regular textured diet. Documentation in the resident's care plan and dietary records failed to indicate any change to a mechanically altered diet or any refusal of such a diet by the resident. Interviews with facility staff, including the Food Service Director and Speech and Language Pathologist (SLP), confirmed that the resident remained on a regular diet and that the hospital's dietary recommendations were not implemented. The SLP noted that it was not within her scope to override the hospital's recommendations and that the resident was educated about the ground diet option, but no formal change was made. The resident reported ongoing issues with chewing and swallowing, particularly due to broken dentures, and expressed fear of another choking incident. Further interviews with the Medical Director, the resident's physician, and the Director of Nursing revealed that all expected the hospital's dietary recommendations to be followed upon the resident's return. The Medical Director emphasized the need for clear physician orders and risk-benefit discussions if the resident chose to deviate from the recommended diet, with appropriate documentation. The physician acknowledged that a mistake occurred in not updating the diet order, and the DON agreed that the failure to change the diet placed the resident at risk. The deficiency was identified as a failure to follow professional standards and hospital recommendations for dietary management after a serious choking event.