Failure to Provide Required Feeding Assistance and Diet Consistency Resulting in Resident Aspiration
Penalty
Summary
A resident with significant cognitive and physical impairments, including neurocognitive disorder, aphasia, dysphagia, and Parkinson's disease, was dependent on staff for full feeding assistance and required a modified diet with ground meat and specific supervision during meals. Despite these documented needs, the resident was left unsupervised in the dining room with a meal that did not meet the prescribed texture requirements. The nurse aide responsible for delivering the tray cut the turkey into smaller pieces but did not remain to feed the resident, as she was assigned to assist another resident at the same time. The aide also reported confusion regarding the resident's feeding requirements and did not recall receiving full feed training prior to the incident. During the meal, the resident began to choke on a piece of turkey, was found drooling, cyanotic, and not breathing by an activities leader, who then called for help. Multiple staff members attempted the Heimlich maneuver and finger sweeps without success, and emergency services were called. The resident was subsequently transferred to the emergency department, where he was diagnosed with aspiration pneumonia and a thoracic aortic aneurysm. The resident's family declined further aggressive interventions, and he was returned to the facility on antibiotics and hospice care. Interviews and record reviews revealed that the resident's care plan and speech therapy recommendations clearly indicated the need for full feeding assistance and close supervision during meals, as well as specific diet modifications. However, staff failed to ensure that the resident received the required level of assistance and the correct meal consistency. The system failure in meal service and staff supervision directly resulted in the resident's aspiration event and subsequent harm.