Failure to Assess and Respond to Choking Incident Following Change in Condition
Penalty
Summary
A deficiency occurred when a resident with dementia and a history of severe cognitive impairment was not assessed by a qualified professional after family reported the resident was choking on liquids. The facility's policy required staff to identify and report changes in a resident's condition, with licensed nurses responsible for initiating communication forms and registered nurses required to assess, notify providers, and document findings. Despite these protocols, there was no documented evidence that a registered nurse or other qualified professional assessed the resident following the family's report of choking, nor was there a referral to speech therapy or an update to the care plan addressing swallowing concerns. The resident had recently returned from the hospital with facial trauma, including multiple nasal fractures, and was experiencing decreased oral intake and difficulty breathing. Progress notes indicated ongoing issues with oral intake and complaints of sore throat, but when the family reported choking on liquids, the LPN checked the resident's mouth but did not document notifying a supervisor or initiating further assessment. No physician orders for diet modification or therapy screenings were completed during this period, and the comprehensive care plan was not updated to reflect the new swallowing concerns. Subsequent documentation showed the resident developed pneumonia and increased lethargy, ultimately leading to death. The autopsy report identified aspiration pneumonia complicating facial trauma as the cause of death. Interviews with staff confirmed that the expected protocol was not followed, as a registered nurse assessment and therapy referral should have occurred after the report of choking, regardless of the family's prior refusal of a modified diet.