Failure to Provide Diet-Appropriate Food Results in Resident Choking Death
Penalty
Summary
A resident with a history of dysphagia, severe cognitive impairment, and multiple comorbidities was admitted with a physician's order for a soft and bite-sized (IDDSI Level 6) diet. The resident's care plan and speech therapy recommendations specified the need for close supervision during meals, encouragement of small bites, and avoidance of foods not consistent with the prescribed diet texture. Despite these documented requirements, the resident was provided a half ham and cheese sandwich as a snack, which did not meet the soft and bite-sized texture criteria and included regular bread, a known choking risk for individuals on this diet. While consuming the sandwich, the resident began to cough and exhibited signs of choking. Staff attempted to assist by performing a mouth sweep and the Heimlich maneuver, but the resident's condition deteriorated, leading to unresponsiveness. Emergency services were called, and CPR was initiated, but the resident could not be revived and was pronounced deceased. Witness statements and nursing notes confirmed that the sandwich provided was not appropriate for the resident's ordered diet and that the resident had a known history of coughing and choking with food, particularly when not closely supervised or when consuming inappropriate textures. Interviews with staff revealed that sandwiches were previously available in the memory care unit's snack refrigerator and that there was a lack of clear, accessible information regarding residents' diet orders at the time of the incident. Staff knowledge of diet textures and the specific requirements for soft and bite-sized diets was inconsistent, and there was no standardized process in place to ensure that only appropriate foods were provided to residents with modified diets. The failure to provide food in a form designed to meet the resident's individual needs directly resulted in the choking incident and subsequent death.