Failure to Prevent Accidental Choking Due to Dietary and Supervision Lapses
Penalty
Summary
A cognitively impaired resident with diagnoses including autism, PICA, severe intellectual disabilities, and schizoaffective disorder was admitted to the facility and required one-person physical assistance with eating, a mechanical soft diet with ground meat, and visual supervision at all times. The resident was known to have behaviors such as putting hands in the mouth and attempting to take other residents' food, which placed him at risk for chewing problems and aspiration. Staff and care plans documented the need for close monitoring and adherence to dietary restrictions. On the day of the incident, the resident was observed attempting to take food from others in the dining room. Staff, including the Administrator and a Certified Medication Aide (CMA), decided to move the resident to his room for his meal. During this time, dietary staff delivered both the resident's prescribed mechanical soft diet and a regular slice of pizza intended for staff into the resident's room. The regular pizza was placed on the opposite side of the table, but the resident impulsively pushed the table, grabbed the pizza, and shoved the entire piece into his mouth. Despite immediate intervention with abdominal thrusts and a call to 911, the resident choked and subsequently died from food bolus asphyxia. Multiple staff interviews confirmed that staff were aware of the resident's dietary restrictions and behavioral risks, and that facility policy prohibited staff from eating in resident rooms or bringing personal food into resident areas. The presence of non-compliant food in the resident's environment, combined with insufficient supervision and failure to remove the hazard, directly led to the resident accessing and consuming food inconsistent with his prescribed diet, resulting in a fatal choking incident.