Failure to Provide Prescribed Diet Texture Results in Choking Incident
Penalty
Summary
A resident with Huntington's disease and dysphagia, who required a mechanically soft diet with thin liquids, was given a bratwurst by a contracted behavioral health aide during an activity program. The aide did not check the facility's logbook, which lists each resident's dietary requirements, before providing the food. As a result, the resident began choking on the bratwurst and required the Heimlich maneuver to clear the airway. The incident was witnessed by another resident and confirmed by the aide, who stated it was only her second day at the facility and she had not verified the resident's diet as required by facility policy. The resident's care plan and physician's orders specified the need for a mechanically altered diet, and the facility's policy required staff to verify diet type and consistency before feeding. Despite these protocols, the failure to check the dietary logbook led to the resident receiving food that was not consistent with her prescribed diet. This deficiency affected one resident directly and had the potential to impact 18 additional residents identified as requiring modified diet textures.