Failure to Provide Correct Diet Texture Resulting in Choking Incident
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including pneumonitis, diabetes, and severe cognitive impairment, was not provided the correct diet texture as ordered. The resident was on a pureed diet with thickened liquids due to her medical condition and risk for choking, as documented in her care plan and physician orders. Despite these orders, the resident was able to obtain and consume corn bread, a food item not consistent with her prescribed diet, during a meal in the dining room. The incident unfolded when the resident took corn bread from another resident's plate and asked a nurse supervisor to open it. The nurse supervisor informed the resident that she was on a pureed diet and could not have the corn bread. However, the resident then obtained another piece of corn bread and asked an agency LPN to open it for her. The LPN, unfamiliar with the resident's dietary restrictions, did not verify the resident's diet order and provided the corn bread. Shortly after consuming the corn bread, the resident began to choke and required the Heimlich maneuver from two nurses to resolve the obstruction. Facility policy required staff to verify diet orders before serving food and to ensure residents received the correct diet texture. In this case, the LPN failed to check the resident's diet order before providing the food item, directly leading to the choking incident. The event was documented in progress notes and incident reports, and interviews confirmed that the LPN had not previously cared for the resident and did not check the diet order prior to assisting her.