F0689

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Failure to Follow Dietary Recommendations Results in Choking Incident

Fayetteville, Pennsylvania Survey Completed on 10-06-2025

Penalty

No penalty information released

Summary

The facility failed to ensure that a resident with specific dietary needs received adequate supervision and assistance to prevent accidents, resulting in a choking incident. The resident had a history of unspecified protein-calorie malnutrition, dehydration, and generalized muscle weakness, and was on a mechanical soft diet with thin consistency. Speech therapy recommendations specified that the resident's food should be cut into bite-size pieces and that small bites or sips should be facilitated during meals. However, these recommendations were not communicated on the resident's meal tray ticket, nor were they consistently followed by staff.

On the day of the incident, an occupational therapist handed the resident half of a beef enchilada, approximately 2.5 inches in size, which was not cut into bite-size pieces as required. Despite verbal and visual cues to take small bites, the resident placed the entire portion in his mouth, leading to choking and labored breathing. Staff present attempted to assist the resident, but the food size and lack of adherence to the recommended feeding techniques contributed to the choking event. The speech therapist later confirmed that staff should have cut the food into smaller portions and that such instructions should have been clearly communicated and followed.

Further review revealed that other residents with similar dietary needs had varying instructions on their meal tray tickets, such as "cut up meats" or "cut food into bite size pieces," but the process for ensuring these directions were consistently applied was lacking. The nursing home administrator acknowledged that speech therapy recommendations should be properly communicated and documented on meal tray tickets, and that staff should follow these recommendations. The failure to communicate and implement individualized dietary precautions resulted in a choking incident and subsequent death, placing additional residents at high risk for similar events.

Plan Of Correction

We were unable to correct deficiency F0689 related to Resident 1 as resident expired in the facility.

Residents 6-14 were screened by Speech Therapy for appropriate diet and checked to see if at risk for choking or require any new safety measures. Director of Rehab audited all current residents that have had a speech therapy diet recommendation to ensure their current diet order reflects speech therapy recommendations. Director of Rehab educated all therapy staff on the new procedure of diet recommendations to be written on the speech therapy recommendation form and physician order as well as provided to nursing. Speech Therapy was also educated to give the speech therapy recommendation form to Dietary. Speech Therapists were instructed if trialing any changes to the diet, the therapist must stay with the resident until the trial item is completed.

The Director of Rehab is conducting an ongoing audit for any new speech therapy recommendations to ensure they match the diet order. All nursing staff was educated prior to the start of their shift on the new choking policy and signs and symptoms to look for with a choking resident. Education was given to all nursing staff prior to the start of their shift on diet and diet textures. Dietary Manager educated all dietary staff prior to the start of their shift on diet and diet textures and cutting up food as indicated on the meal ticket.

Dysphagia/Choking Procedure in-service was provided to the staff by Anthony Clark, Director of Nursing, and Talayne Gates, SLP, on Tuesday, October 14th at 7am, 1pm, and 3pm, and will be provided on Thursday, October 16th at 7am, 1pm, and 3pm to licensed staff and nursing assistants. The Director of Nursing and Assistant Dietary Manager are conducting audits of all new dietary orders or changes and recommendations for meal ticket accuracy through October 31, 2025. The Dietary Manager audited all meals during tray line service to ensure meal ticket matches diet order and visually observe meal served is accurate through 10/10/25. Beginning 10/13/25, the Dietary Manager will audit 3 meals per week during tray line to ensure meal ticket matches diet order and visually observe meal served is accurate through October 31, 2025.

Direct in-service training on F0689, Accidents and Incidents, for all licensed staff and nursing assistants will be provided by Sophie Campbell, MSN, RN, CRRN, RAC-CT, CNDLTC. Sophie Campbell is the Executive Director of the Pennsylvania Association of Directors of Nursing Administration and is an approved directed in-service provider on the list from the Department of Health. The in-service will be held on Wednesday, October 29th at 7am, 1pm, and 3pm. This in-service will be recorded for staff that is unable to attend. Licensed staff unable to attend the in-service will be required to watch the recorded in-service prior to the start of their next shift. All ongoing audits will be reviewed at the monthly QAPI to determine if further auditing is needed.

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Removal Plan

• Choking policy was reviewed and updated to American Heart Association Standards.
• All nursing staff currently working in the building will be educated by Employee 6 (Assistant DON) on the revised choking policy.
• All other nursing staff will be educated by the Registered Nurse (RN) Supervisor prior to the start of their shift. This will include all full time, part-time and nursing staff.
• Employee 6 will educate all nursing staff currently working on the signs to look for when someone is choking.
• All other nursing staff will be educated by the RN Supervisor prior to the start of their shift. This will include all full time, part-time and nursing staff.
• Employee 7 audited all residents on current caseload to ensure current speech therapy diet recommendations were being followed.
• Employee 7 will audit all residents who have had current speech therapy diet recommendations to ensure their current diet order reflects speech therapy recommendations.
• Employee 7 will educate speech therapists on new procedure to write recommendations on speech therapy recommendation form and physician orders.
• Employee 7 will educate Employee 1 on following dietary orders.
• Employee 12 (Dietary Manager) will educate dietary staff currently working on diet and diet textures.
• All other dietary staff members will be educated by Employee 12 prior to the start of their shift. This will include all full time, part-time, and as needed staff.
• All nursing staff currently working in the building will be educated by Employee 6 on diets and diet textures and to read and follow meal tickets.
• RN Supervisor will educate all nursing staff currently working on diets and diet textures and to read and follow meal ticket directions.
• Employee 12 (Dietary Manager) audited evening meal service tray line to ensure meal tickets matched diet order and visually observed meal service was accurate.
• All meals will be audited during tray line to ensure meal ticket matches diet order and visually observe meal served is accurate.