Failure to Revise Dysphagia Care Plan After Repeated Choking Incidents
Penalty
Summary
A deficiency occurred when the facility failed to review and revise a resident's dysphagia care plan in response to repeated choking episodes and recommendations from a Speech Language Pathologist (SLP). The resident, who had a history of dysphagia, dementia, and right-side hemiplegia following a stroke, experienced multiple choking incidents that required staff to perform the Heimlich Maneuver. Despite these events and the SLP's recommendation for direct supervision during meals, the care plan was not updated to include this intervention, and the resident continued to be supervised only from a distance. The resident's care plan was initially updated after a choking episode to downgrade the diet and provide education on safe eating practices. However, after subsequent choking incidents, including those where the resident expelled large pieces of unchewed food, the only intervention added was re-education on taking small bites and alternating with sips. The SLP evaluation specifically recommended direct supervision with oral intake, but this was not incorporated into the care plan, nor was it implemented in practice. Staff interviews confirmed that no one was assigned to provide direct supervision during meals, and documentation of education or further SLP referrals was lacking. The failure to revise the care plan and implement direct supervision as recommended by the SLP persisted despite ongoing choking episodes. Ultimately, the resident choked during a meal, was found unresponsive, and died despite staff intervention. The facility's own investigation and staff interviews confirmed that the SLP's recommendations were not added to the care plan, and no new interventions were implemented following repeated incidents.