Failure to Develop and Implement Care Plan for Dysphagia Leading to Fatal Choking Incident
Penalty
Summary
The facility failed to provide care in accordance with professional standards by not developing and implementing a care plan for a resident with a documented history of dysphagia, despite clear recommendations from speech therapy for swallowing and aspiration precautions. The resident, who had diagnoses including acute respiratory failure, oropharyngeal dysphagia, COPD, and mild cognitive impairment, was admitted with a need for supervision or touching assistance during eating. Speech therapy recommended a mechanical soft diet, thin liquids, and strict aspiration precautions, including eating slowly, taking small bites, and sitting upright. However, these recommendations were not incorporated into the resident's care plan, and staff were not consistently aware of or implementing these precautions. During a meal, the resident was served a turkey hotdog in a bun and was being supervised by a CNA, who offered assistance with cutting the food but was refused by the resident. The CNA did not provide verbal cues or reminders to eat slowly or take small bites, as recommended by speech therapy. The resident began choking, and staff attempted the Heimlich maneuver and suctioning, but only small pieces of food were expelled. There was inconsistency among staff regarding the resident's swallowing precautions, with some staff unaware of the need for aspiration precautions and others stating that supervision and cuing were required. After the choking episode, the resident initially appeared alert and responsive according to facility staff, but EMS found the resident unresponsive with low oxygen saturation upon arrival. The resident was transported to the hospital, where she expired en route. Interviews with dietary and clinical staff revealed a lack of awareness and implementation of a care plan addressing the resident's swallowing difficulties, and the dietary care plan only addressed food preferences, not swallowing safety. The facility's policy required a comprehensive care plan to address all identified needs, but this was not done for the resident's dysphagia.