Failure to Supervise Resident with Choking Risk During Meals Resulting in Death
Penalty
Summary
A deficiency occurred when staff failed to provide required supervision and assistance during mealtime for a resident with a known history of choking incidents and an established care plan requiring assistance with dining. The resident had diagnoses including hemiplegia and hemiparesis following a cerebral infarction, and was cognitively intact. The care plan specified a mechanical soft diet with chopped meats and required staff assistance with meal setup and feeding due to previous episodes of choking and difficulty with certain food textures. Despite these documented needs, the resident was left unsupervised while eating in their room. Multiple nursing notes and care plan entries indicated the resident had previously choked on meats, had been observed coughing frequently during meals, and had expressed concerns about getting 'strangled' on tough meat. On the day of the incident, the resident was found alone in their room, in distress and choking, with no staff present to provide immediate assistance. Staff were occupied distributing meal trays in the hallway at the time. When the resident activated the call light, a CNA responded and found the resident choking, attempting to perform the Heimlich maneuver with assistance from another CNA and an LPN. Despite these efforts, the resident was pronounced dead by EMS. Interviews with staff confirmed that the resident was not being monitored during the meal, contrary to the care plan and facility policy, which required supervision and assistance for residents at risk of choking.
Removal Plan
- Review all residents' nutritional care plans and diets for choking risk, non-compliance with diets, therapeutic diets, and assisted feeding needs.
- Identify residents at risk of choking or non-compliance with diet orders/recommendations or who require assistance with feeding.
- Update nutritional care plans for all residents identified as choking risk by clinical staff.
- Create a quick reference chart (diet reference list) for all clinical and dietary staff, including meal location preferences, diet (including consistency), portion, and protein supplements; place the chart at the nurse's station, in the nurse shift book, in the kitchen on the bulletin board, and in the CNA shift report book.
- Create a policy addendum on choking or dietary non-compliance and add it to the assistance with meals policy, including key personnel to contact regarding choking or dietary non-compliance events and assessment of the resident to determine the need for treatment such as the Heimlich maneuver.
- Create and implement a CPR policy and procedure specifying when to initiate CPR, training and competency requirements, require all clinical staff to maintain valid CPR/BLS certification, require newly hired staff to obtain CPR certification, require CPR recertification, allow a grace period for renewal, and maintain proof of certification in personnel files.
- Provide in-service education for all clinical staff on supervision during meals, including procedures for meal supervision and 1:1 staff presence for residents requiring feeding assistance or at risk of choking.
- Provide in-service education on how to locate and follow care plans in the electronic health record, and instruct staff to notify the charge nurse if they cannot access needed information.
- Provide in-service education on procedures related to a choking event, including identification of choking risk residents, reporting choking events, and reporting dietary compliance issues.
- Train all clinical staff on CPR and Heimlich maneuver.
- Conduct a Quality Assurance Performance Improvement Project (PIP) to address assisting and monitoring residents named as choking risk and 1:1 supervision of residents during mealtimes until meal is completed.
- Implement quality assurance monitoring: monitor residents at risk for choking by DON/designee.