Failure to Timely Assess and Intervene After Choking Incident
Penalty
Summary
A resident with a history of stroke was admitted to the facility and had documented issues with coughing and choking during meals and when swallowing medications. The resident was on a dental/mechanical soft texture diet with nectar thick liquids per physician orders. On one occasion, the resident choked during dinner, requiring the Heimlich maneuver to be performed by an LPN, after which the resident recovered. Despite this significant choking episode, the resident's diet was not immediately downgraded, and there was no evidence that the speech-language pathologist was notified following the incident. The LPN involved acknowledged that the resident's diet should have been changed to puree at the time of the choking event but did not take this action. The Director of Rehabilitation was not informed of the choking incident until three days later, at which point the diet was downgraded and a consultation with the speech-language pathologist was initiated. The Director of Nursing Services also confirmed that the diet should have been downgraded immediately after the choking episode. The delay in assessment and intervention following the resident's change in condition constituted the deficiency.