Failure to Provide Prescribed Pureed Diet Results in Choking Incident
Penalty
Summary
A deficiency occurred when a resident who required a pureed diet due to severe cognitive impairment and multiple medical conditions was provided with a whole hot dog, a regular texture food item, instead of the prescribed pureed meal. The resident's medical records indicated a need for a mechanically altered diet with pureed texture and nectar consistency fluids, as ordered by the physician and documented in the care plan. Despite these clear dietary requirements, the resident received a tray containing a whole hot dog, which was not checked by a nurse before being delivered to the resident's room. The incident took place when a CNA delivered the food tray to the resident and assisted with the meal. The CNA's statement revealed that the resident immediately grabbed the hot dog and began eating it, leading to a choking episode. The CNA attempted to intervene, but the resident began to show signs of distress, prompting the CNA to call for help. The ADON responded, performed the Heimlich maneuver, and recovered pieces of regular bread and meat from the resident's mouth. Despite these efforts, the resident became unconscious and required CPR before being transferred to the hospital, where an anoxic brain injury was diagnosed. Interviews with facility staff, including the dietary aide, kitchen manager, DON, and Administrator, confirmed that the resident was given the incorrect food texture due to a mix-up in the kitchen and a failure to follow established procedures for verifying meal trays. The dietary aide and kitchen manager acknowledged that the resident's tray should have contained pureed food, and the DON and Administrator confirmed that staff did not adhere to the policy requiring nurse verification of trays before service. The investigation determined that the kitchen sent out the wrong tray, and staff failed to check the tray against the resident's dietary orders before it was served.