Failure to Prevent Choking Death Due to Inadequate Supervision and Aspiration Precaution
Penalty
Summary
A deficiency occurred when a severely cognitively impaired resident, who was at risk for aspiration and choking and required supervision during meals, was found unresponsive in a hallway late at night. The resident had a documented history of wandering, taking other residents' food, and required a puree and nectar thick liquid diet with soft sandwiches. The resident wore a green charm indicating aspiration risk and was supposed to be closely supervised, especially during meals and when in common areas. Despite these precautions, the resident was last seen in the hallway and was later found unresponsive in their wheelchair with food, including peanut butter and meat, lodged in their airway. Staff interviews and documentation revealed that the resident was not being adequately supervised at the time of the incident. Certified Nursing Assistants and nurses on duty were either unaware of the resident's whereabouts or did not recognize the need for immediate intervention when food was observed in the resident's mouth. The staff did not perform appropriate emergency measures such as suctioning the airway, and there was confusion about the timeline and actions taken during the emergency response. The facility's policy required close observation and intervention for residents with aspiration risk, but these protocols were not followed, as evidenced by the lack of supervision and failure to prevent the resident from accessing and consuming unsafe food. The incident resulted in the resident's death due to choking and aspiration, as confirmed by emergency medical services who found large amounts of food obstructing the airway. The facility's documentation and staff statements indicated gaps in monitoring, supervision, and adherence to established aspiration precautions. The deficiency was identified as Immediate Jeopardy due to the actual harm and death of the resident and the potential for serious harm to other residents at risk for aspiration.
Removal Plan
- Hold a Quality Assurance Performance Improvement meeting addressing the immediate jeopardy citation (F689), root cause and scope determination, immediate corrective actions, directed plan of correction and monitoring and validating plan.
- Reeducate the Nursing staff, Dietary and Speech Therapists regarding resident safety and supervision, aspiration precautions and emergency response.
- Conduct a chart audit on residents to ensure residents are assessed for aspiration and wandering behavior. Implement physicians' orders and update care plans.
- Review Policies and Procedures on Cardiopulmonary Resuscitation and Heimlich Maneuver.
- Revise the Cardiopulmonary Resuscitation policy and procedure to include not to move the resident to the bed or another area, begin cardiopulmonary resuscitation where the resident is found.
- Revise the Heimlich Maneuver policy and procedure to include to lower resident to a firm surface and activate Emergency Medical Service (911), begin cardiopulmonary resuscitation starting with compressions, before delivering breaths during cardiopulmonary resuscitation cycles, open mouth and look for visible object, remove only if seen, do not perform blind finger sweeps.
- Reevaluate all locations of nourishment and snacks on the units to ascertain if current measures to secure said nourishment is adequate.
- Initiate in-service education to Certified Nursing Assistants, Licensed Nurses, Speech Therapist and Dieticians regarding residents at risk for aspiration, facility safety practices, policy update, rounding and documentation, and environmental safety measures.
- Provide staff in-service on resident safety and supervision, aspiration precautions and emergency response.