Failure to Prevent Resident Access to Restricted Food Resulting in Choking Event
Penalty
Summary
A resident with diagnoses including Parkinson's disease, dementia, dysphagia, and depression, and a moderate cognitive impairment, was identified as requiring a mechanically altered diet and supervision during meals. The resident's care plan specified the need for a minced and moist diet, set-up assistance, and supervision for dietary intake due to impaired decision-making skills and risk for complications related to dysphagia. Despite these documented needs, the resident was able to access the nursing unit's refrigerator, which was located in an open alcove accessible to residents, staff, and visitors, and obtain a regular consistency sandwich without staff assistance. Multiple nursing notes indicated that the resident had previously been observed entering the refrigerator and seeking food, and staff had provided snacks or redirected the resident on those occasions. However, on the day of the incident, the resident was not observed until after they had accessed and consumed part of a sandwich independently. The resident subsequently experienced a choking event, was found holding their throat and unable to respond verbally, and required the Heimlich maneuver to clear the airway obstruction caused by turkey meat from the sandwich. Interviews with staff and facility leadership confirmed that the refrigerator was routinely stocked with snacks and sandwiches and was accessible to residents. Staff acknowledged that the resident required supervision when out of bed and that the expectation was for residents to be visualized every two hours unless otherwise ordered. The facility did not have a policy regarding supervision of residents, and the lack of adequate supervision allowed the resident to obtain and consume a restricted food item, resulting in a choking incident.