Failure to Implement Swallowing Precautions and Emergency Response for Resident with Dysphagia
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a care plan for a resident with a documented history of dysphagia, despite recommendations from speech therapy for swallowing precautions. The resident was admitted with multiple diagnoses, including acute respiratory failure, dysphagia, COPD, and mild cognitive impairment. The resident's Minimum Data Set indicated a need for supervision or touching assistance with eating, and speech therapy recommended a mechanical soft diet with strict aspiration precautions. However, the care plan did not address the resident's swallowing difficulties or include specific interventions for aspiration precautions. During a mealtime, the resident was allowed to eat independently, despite her history and recommendations for supervision and assistance. The certified nurse assistant (CNA) offered to assist, but the resident refused, and the CNA did not provide verbal cues or reminders to eat slowly or take small bites, as recommended by speech therapy. The resident began to choke while eating, and staff attempted the Heimlich maneuver and called for additional help. Multiple staff members performed abdominal thrusts, but the food was not fully expelled, and the resident became unresponsive. There was confusion among staff regarding the proper technique for the Heimlich maneuver, and the resident was found by EMS to be unresponsive with low oxygen saturation. Interviews revealed inconsistent understanding among staff regarding the resident's need for aspiration precautions and the appropriate interventions during a choking event. Some staff were unaware of the resident's dysphagia, and dietary and nursing staff did not coordinate to ensure the care plan reflected the resident's swallowing risks. The facility's policies required comprehensive care planning and specific emergency procedures for choking, but these were not followed, resulting in the resident's choking incident and subsequent death during transport to the hospital.