Failure to Provide Required Mealtime Supervision Resulting in Choking Incident
Penalty
Summary
The facility failed to provide adequate supervision to prevent a choking incident for a resident with significant risk factors, including Parkinson's Disease, dysphagia, and a history of stroke with left-sided weakness. The resident was identified as requiring supervision during meals due to aspiration risk, as evidenced by coughing with food and drinks and a tendency to inhale food and gulp liquids. Despite this, the resident was left unsupervised during breakfast, resulting in a choking episode where the resident was found coughing, with a red face, and unable to speak, requiring immediate intervention by nursing staff. Interviews and observations revealed that although the Assistant Director of Nursing (ADON) had instructed a Certified Nursing Assistant (CNA) to supervise the resident during breakfast, the CNA was unaware of the supervision requirement and did not remain with the resident. The facility's whiteboard indicated the need for supervision, and both the ADON and Director of Nursing (DON) confirmed the importance of following such instructions for residents at risk of aspiration. The facility's policies reviewed did not provide specific guidance on supervision to prevent aspiration or choking, contributing to the deficient practice.