Failure to Prevent Choking and Falls Due to Inadequate Supervision and Implementation of Precautions
Penalty
Summary
A resident with a history of cerebral vascular accident, schizoaffective disorder, epilepsy, mild intellectual disabilities, and congestive heart failure was placed on a pureed diet due to dysphagia and difficulty chewing. Despite these precautions, the resident was left unsupervised in the dining room when staff left the table to clean, allowing another resident to place a regular-texture fruit cup in front of him. The resident consumed the whole food, choked, and required the Heimlich maneuver, which was initially unsuccessful. Emergency services were called, and the resident was transported to the hospital with ongoing respiratory distress and altered mental status. The same resident was also identified as being at risk for falls due to a seizure disorder, history of stroke with mild right foot drop, mild developmental disability, and previous falls. The care plan included the use of a Dycem pad in the recliner to prevent sliding. However, the resident experienced an unwitnessed fall when the Dycem pad was not in place as required, resulting in the resident sliding out of the recliner. No injuries were reported from this incident. Another resident, recently admitted with diagnoses including rhabdomyolysis, acute kidney failure, dementia, epilepsy, and femur fracture, was assessed as high risk for falls. The care plan required the bed to be in the lowest locked position. The resident was found on the floor after the bed, which was not locked, moved while the resident attempted to get out of bed. No injuries were noted, but the incident was attributed to the failure to lock the bed as required by the care plan.