Failure to Enforce Dietary Restrictions and Supervision Leading to Choking Incidents
Penalty
Summary
The facility failed to provide adequate administrative oversight, resulting in a resident's death due to choking after being given food items that were not approved for their diet. Despite a requirement for staff to use diet order cards on snack trays to ensure residents received appropriate food, observations revealed that staff were not consistently utilizing these cards during snack distribution. Additionally, a resident who required supervision while eating was observed eating alone and subsequently began choking, with staff intervention needed to resolve the incident. Another resident on a pureed diet was seen taking bacon from another resident's meal tray left unattended in the hallway, despite staff being aware of this resident's tendency to take food from others and the need for close monitoring. Medical record reviews confirmed that the residents involved had specific dietary restrictions and supervision requirements that were not followed. Staff interviews corroborated that the required practices, such as using diet order cards and supervising residents during meals, were not consistently implemented. The facility's policies and job descriptions outlined the responsibility of administration to ensure proper procedures and quality of care, but these were not effectively enforced, leading to multiple incidents where residents received inappropriate food or were left unsupervised during meals.