Failure to Supervise Resident During Meals Resulting in Fatal Choking Incident
Penalty
Summary
A facility failed to provide necessary supervision to prevent an avoidable accident involving a resident with severe cognitive impairment, a history of stroke, dementia, and dysphagia, who was on a pureed diet with nectar thick liquids. The resident required staff assistance with eating due to an inability to control the speed and quantity of food intake, as documented in the care plan, Kardex, and speech therapy notes. Despite clear instructions and repeated education to staff that the resident needed supervision during meals to prevent rapid, impulsive self-feeding and reduce the risk of aspiration or choking, a nurse aide left a meal tray in front of the resident and exited the room to deliver other trays. Shortly after the meal trays were distributed, another nurse aide found the resident unresponsive and not breathing, with food in his mouth. Nursing staff initiated CPR and called EMS, who arrived and took over resuscitation efforts. The resident was transported to the hospital, where he was intubated after a second cardiac arrest and admitted to the ICU. Hospital records and the death certificate confirmed that the cause of death was airway occlusion by a bolus of food. Interviews with staff, including nurse aides, nurses, the speech therapist, the DON, the administrator, the nurse practitioner, and the medical director, confirmed that the resident was known to require supervision during meals due to impulsive eating behaviors and high risk of choking. The nurse aide who left the tray was new, had not previously worked with the resident, and had been incorrectly informed by other aides that the resident could feed himself without assistance. The failure to provide required supervision directly led to the resident being left alone with food, resulting in choking and subsequent death.
Removal Plan
- Resident #132 was provided with his breakfast tray by Nurse Aide #8, who walked out of the resident's room.
- The charge nurse completed a Risk Management and Situation Background Assessment Recommendation (SBAR). The Administrator, Director of Nursing, Medical Director, and Responsible Party were all notified.
- Resident #132's diet consistency, supervision needs, and feeding requirements were reviewed by the Director of Nursing and Administrator. The Registered Dietician confirmed that Resident #132 was appropriate for a puree diet with thickened liquids, with staff supervision required during meals.
- A root cause analysis was determined by the Administrator, Director of Nursing, and Eastern Regional Administrator that Nurse Aide #8 did not provide resident supervision during meal. Nurse Aide #8 was suspended pending investigation.
- Nurse Management/designee reviewed all residents' kardex and audited the assistance level required while feeding. It was concluded that 9 residents were dependent on staff for feeding and 7 residents required supervision of staff.
- DON #1/designee completed observation rounds during lunch and dinner meals on the identified residents that needed feeding assistance with no other concerns identified.
- Nurse Management initiated a facility-wide education for all licensed nurses/NAs on meal delivery and feeding assistance, focusing on proper resident identification, verification of correct diet orders, and adherence to required supervision levels during meals.
- Licensed nurses/NAs were educated on utilizing the kardex to locate information needed to determine supervision required with feeding.
- No licensed nurses/NAs are permitted to work without education in meal tray delivery until they have completed this required education.
- All licensed nurses/NAs were educated by Nurse Management or the Administrator via phone or with one-on-one in-service.
- The only staff that pass resident meal trays are NAs/licensed nurses.
- This training has been added to the orientation program for all licensed nurses/NAs.
- The Director of Nursing, Nurse Manager, and Administrator will conduct audits of resident meal tray delivery. These audits include validation of accurate meal tickets, correct resident identification, and confirmation that residents receive the correct diet with the required level of assistance as indicated on the resident Kardex and diet order.
- Audits are done two meals per day, five days per week for six weeks. Any concerns identified will be addressed and corrected immediately.
- Results of these audits will be reviewed during the QAPI meeting to determine whether additional monitoring is needed.
- The Administrator is responsible for ensuring completion and oversight of this Plan of Correction.