Neglect Due to Failure to Follow Dietary Consistency Leading to Choking Incident
Penalty
Summary
A deficiency occurred when a Certified Nurse Aide failed to follow a resident's care plan regarding dietary meal consistency, resulting in the resident being served food of the wrong texture. The resident, who had diagnoses including dementia with agitation, chronic obstructive pulmonary disease, and bladder cancer, was assessed as cognitively severely impaired and required a mechanically altered diet with ground meats due to dysphagia and impaired swallowing. The resident's care plan and dietary assessments clearly indicated the need for a mechanical soft diet with minced meats, and the meal ticket on the resident's tray specified this requirement. During a supper meal, the Certified Nurse Aide intentionally swapped meal plates among three residents, providing the resident with regular chicken tenders instead of the required minced consistency. Despite being warned by another aide that the food was not the correct consistency, the aide proceeded to feed the resident the regular chicken. This resulted in the resident choking and requiring immediate intervention, including back thrusts and mouth sweeps, to clear the airway. Staff interviews confirmed that the aide did not read the meal ticket and failed to follow established procedures for obtaining alternative meals, such as contacting the kitchen. Facility policies and staff education materials emphasized the importance of following care plans, meal tickets, and dietary restrictions to prevent neglect and ensure resident safety. The incident was witnessed by multiple staff members, and statements from nursing and medical staff indicated that the aide's actions were negligent and directly led to the resident's choking episode. The failure to adhere to the resident's prescribed diet and established protocols constituted neglect as defined by facility policy.