Failure to Implement Aspiration and Choking Prevention Care Plan
Penalty
Summary
A deficiency occurred when the facility failed to implement the care plan to prevent aspiration and/or choking for a resident assessed as being at risk. The resident had a history of mood affective disorder, dementia, and dysphagia, and was dependent on staff for activities of daily living. The care plan included monitoring the resident's tolerance to diet and fluids, assessing for signs and symptoms of aspiration, and involving speech therapy as indicated. The resident's diet had been changed to a puree texture with nectar/mildly thick consistency following episodes of delayed swallowing and coughing on liquids. Despite these interventions, multiple observations showed that the resident experienced repeated episodes of coughing while being fed by a CNA, both during meals and in occupational therapy. The CNA continued to feed the resident after several coughing episodes, only stopping after persistent coughing. The CNA attempted to manage the coughing by giving the resident thickened water and milk, but the coughing continued. Food and fluids remained on the tray after feeding was stopped. Interviews with staff revealed that the CNA did not notify nursing staff about the resident's repeated coughing during meals, and the DON was not made aware of the situation. The facility's policy required staff to identify and respond to signs of swallowing difficulties, including notifying appropriate personnel and seeking further evaluation by a speech therapist. These steps were not followed, resulting in a failure to fully implement the care plan for aspiration and choking prevention.
Plan Of Correction
F-tag: 656 Develop/implement Comprehensive Careplan Immediate corrective action: On 05/02/25, DON reassessed Resident 32 and implemented the plan of care to prevent risk of aspiration and choking. On 05/02/25, DON/DSD provided 1:1 in-service/re-training, and re-education to CNA 13 regarding policy on "Dysphagia." Emphasized to stop feeding the resident if any signs and symptoms of coughing are noticed, and to report to RN/Charge Nurse for further evaluation and notification of MD and responsible party. On 05/02/25, ST (Speech Therapist) evaluated Resident 32 and obtained an order for ST treatment for diet texture analysis and management, compensatory strategies training, and caregiver education training. Identification of others at risk: MDS Coordinator / MDS assistants continued to review residents' care plans with diagnosis of Dysphagia on 05/02/25 and 05/20/25. No additional discrepancies were identified with the same deficient practice. Process to prevent recurrences: On 05/02/25 and 05/20/25, DON provided in-services to nursing staff (CNA, LVN, RN) regarding policy on "Dysphagia," emphasizing the importance of the following: - To stop feeding the resident if any signs and symptoms of coughing are noticed during feeding. - To report observation immediately to RN supervisor or charge nurse for further assessments. In-services were given by the DON on 05/02/25 and 05/20/25 to reinforce to MDS staff (RN, LVN) their responsibility for accuracy in resident care plans to accurately reflect residents' current medical status. Monitoring process: The MDS Coordinator will review resident care plans with diagnosis of Dysphagia x 3 months to ensure care plans reflect residents' current medical status. The MDS Coordinator will report to the Administrator for review of findings, and any deficient practices identified will be discussed during the monthly CQI/QA meeting for further recommendation and resolution. Completed date: 5/20/2025