Failure to Provide Timely Assessment and Adherence to Aspiration Precautions During Choking Incident
Penalty
Summary
A resident with severe cognitive impairment, aphasia, and Alzheimer's disease experienced a choking episode in the dining room while being fed by a family member. Nursing staff present in the dining room did not immediately identify or address the choking incident, despite being responsible for supervision during mealtimes. The resident continued to cough and vomit, and was only attended to after a family member flagged down a nurse. The staff present, including the Director of Staff Development (DSD) and a Licensed Vocational Nurse (LVN), did not provide prompt intervention as required by facility policy and their training. Following the choking episode, a comprehensive assessment was not completed for the resident. The DSD performed only a limited abdominal assessment and did not evaluate for respiratory distress, airway obstruction, or oral cavity issues, which are necessary after such an event. The DSD delegated monitoring of the resident to a Hospitality Aid (HA), a non-nursing staff member whose role does not include direct care or clinical assessment. The incident was not reported to the resident's primary nurse, and the HA was only instructed to watch the resident for safety, which was not appropriate given the seriousness of the choking event. Additionally, the family member who routinely fed the resident was not provided with education on safe feeding techniques or aspiration precautions, despite the resident being on a pureed diet with nectar-thickened liquids and specific swallow strategies outlined by the speech therapist. Observations showed the family member feeding the resident large bites and thin liquids, contrary to the care plan and physician orders. The facility also failed to ensure that the resident received the prescribed thickened liquids, as the resident was observed consuming thin liquids during meals. These failures resulted in the resident's needs being unidentified and improper assessment and care during a choking episode.