Failure to Provide Timely Assessment and Supervision for Resident on Aspiration Precautions
Penalty
Summary
A deficiency occurred when a resident with a history of schizophrenia, severe cognitive impairment, and a known risk for aspiration and choking was found unresponsive in a hallway. The resident was on aspiration precautions, wore a green charm indicating swallowing difficulty, and required supervision during meals. Despite these documented risks and care plan interventions, the resident was not adequately supervised and was able to access and consume food unsupervised, which was not consistent with their prescribed dietary and safety requirements. When the resident was discovered unresponsive in their wheelchair, staff did not immediately assess the resident or initiate cardiopulmonary resuscitation (CPR) as required by facility policy. There was a delay in both the assessment and the initiation of emergency procedures, including calling Emergency Medical Services (EMS), which occurred approximately 15 minutes after the resident was found. Documentation and interviews revealed inconsistencies in staff awareness and response, with some staff noting the presence of food in the resident's mouth and others not recognizing or acting upon this critical finding. Upon EMS arrival, the resident was found to have a large amount of food, including peanut butter and meat, lodged in their airway, which required clearing and suctioning before further resuscitation efforts. The resident was pronounced deceased after unsuccessful resuscitation attempts. The facility failed to provide care and treatment in accordance with professional standards, the resident's care plan, and the resident's known preferences and goals, resulting in actual harm.