Failure to Provide Correct Diet Texture Resulting in Choking Incident
Penalty
Summary
A deficiency occurred when a resident with dementia and oropharyngeal dysphagia was not provided with the correct textured diet as ordered. The resident's care plan and physician orders specified a mechanical soft texture with thickened liquids, but on the day of the incident, the resident was served a whole bratwurst on a bun, which did not meet the mechanical soft diet requirements. Multiple staff, including the CNA, cook, and dietary aide, confirmed that the resident received the incorrect diet texture, and the facility's dietary records and recipes indicated that the meal should have been ground bratwurst with gravy to ensure proper consistency. During lunch, the resident choked on the improperly prepared food, became unresponsive, and required emergency intervention. Staff performed abdominal thrusts and a finger sweep to remove the food obstruction, after which the resident regained consciousness and normal color. Emergency medical services were called, and the resident was transported to the hospital for further evaluation and care. The incident was documented in progress notes, incident reports, and confirmed by interviews with staff present at the time. The facility's own dietary policy and menu documentation outlined the requirements for mechanical soft diets, including that meats be ground or chopped into small, moist pieces. Despite these guidelines, the resident was served a regular texture meal, which directly led to the choking event. Staff interviews revealed a lack of awareness regarding the resident's current diet order at the time of meal service, contributing to the failure to provide the appropriate diet texture as ordered.