Failure to Provide Required 1:1 Supervision During Meals Resulting in Choking Incident
Penalty
Summary
A deficiency occurred when staff failed to follow a physician's order requiring one-to-one (1:1) supervision during meals for a resident with multiple diagnoses, including bipolar disorder, diabetes mellitus, and mild oropharyngeal dysphagia following an anterior cervical discectomy and fusion. The resident's care plan and physician's order specified a dysphagia level 3 diet with thin liquids and mandated 1:1 supervision and assistance with feeding, including cues for small bites, small sips, and alternating solids with liquids. Despite these orders, staff delivered a piece of cake to the resident and left it on the overbed table without remaining present to provide the required supervision. Subsequently, the resident was found to be having difficulty breathing after consuming the dessert without supervision. Staff attempted abdominal thrusts and called emergency services, resulting in the resident's transfer to the hospital, where aspiration was diagnosed. Interviews with staff and the DON confirmed that the facility's policy and the physician's order for 1:1 supervision were not followed at the time of the incident, as staff were distributing meals and intended to provide supervision only after all trays had been delivered.