Failure to Provide Required Mealtime Supervision Resulting in Choking Incident
Penalty
Summary
A deficiency occurred when a resident with a history of hemiplegia, hemiparesis, dysphagia, aphasia, apraxia, epilepsy, and dementia did not receive the required supervision during mealtime as outlined in their care plan. The resident's care plan specified that all meals and fluid intake should occur under staff supervision due to swallowing difficulties. Despite this, the resident was left unsupervised during lunch, which resulted in a choking incident that required the Heimlich maneuver and emergency intervention. The resident had recently been discharged from speech therapy, which had reiterated the need for mealtime supervision due to swallowing safety concerns. However, the speech therapist did not verbally communicate the supervision requirement to the nursing staff, as the diet remained unchanged and the care plan already indicated supervision was needed. Nursing assistants and other staff members were unaware of the supervision requirement, as the resident's care card only indicated setup assistance for meals, not supervision. This miscommunication and lack of awareness led to the resident being left alone while eating. Interviews with staff revealed that the care plan interventions, including supervision with eating, were not correctly reflected on the quick-reference care cards used by nursing assistants. As a result, multiple staff members believed the resident only required setup assistance and not active supervision. This failure to ensure proper communication and implementation of the care plan directly contributed to the resident's choking incident.