Failure to Provide Correct Food Consistency Results in Choking Incident
Penalty
Summary
The facility failed to provide food in the correct consistency as ordered by the physician and required by the resident's individual needs. One resident, who was on a Dysphagia Advanced texture diet, was served broccoli that was not chopped to the required pea-size pieces. The resident experienced a choking episode while eating, which required immediate intervention by staff and a visitor, including the Heimlich maneuver and manual removal of a broccoli chunk from the resident's throat. The resident was subsequently transferred to an acute care facility and hospitalized. Review of documentation and staff statements revealed that the dietary staff did not consistently follow the prescribed diet modifications, with one staff member stating they were not instructed to chop broccoli. The facility's meal distribution plan indicated that both dietary and nursing staff were responsible for verifying meal accuracy, but this process failed to prevent the incident. The deficiency was identified as having the potential to affect multiple residents, as several others were also on modified diets.