Failure to Supervise Cognitively Impaired Resident with Dysphagia Results in Fatal Choking Incident
Penalty
Summary
A facility failed to provide necessary supervision to prevent an avoidable accident involving a severely cognitively impaired resident with a history of dysphagia and choking. The resident was prescribed a pureed diet with honey-thick liquids and required close supervision and assistance with feeding due to poor safety awareness and impulsivity. Despite these needs, the care plan did not include specific interventions for supervision during meals, and staff were not consistently monitoring the resident's access to food outside of prescribed meals. On one occasion, the resident experienced a choking episode in the main lobby after obtaining bread, which was not part of his prescribed diet. Staff intervened and the resident returned to baseline. Following this incident, staff were educated on the importance of adhering to prescribed diets, but no additional supervision measures were implemented. Subsequently, the resident accessed a hot dog from an unattended meal cart, began to choke, and despite staff performing abdominal thrusts and CPR, the resident was pronounced deceased after EMS was unable to revive him. Multiple staff interviews confirmed that the resident was known to seek food and had previously taken food from meal carts or other sources when not closely supervised. The facility's failure to implement and maintain adequate supervision and environmental controls, such as securing meal carts and monitoring residents with known food-seeking behaviors and swallowing disorders, directly contributed to the resident's access to unsafe food and the fatal choking incident. Staff awareness of the resident's risks and behaviors was inconsistent, and interventions to prevent access to inappropriate food were not effectively communicated or enforced.