Failure to Follow Physician-Ordered Therapeutic Diet Results in Choking Incident
Penalty
Summary
A deficiency occurred when the facility failed to follow the physician's recommended therapeutic diet for a resident with a history of cerebral vascular accident and dysphagia. The resident had been assessed by speech therapy and a barium swallow study, both of which recommended a Level 5 minced and moist diet with specific restrictions, including no regular dry bread or mixed consistencies, and required supervised feeding. The care plan and physician's order reflected these recommendations. Despite these clear directives, the resident was served a meal that was not properly prepared according to the prescribed diet, specifically a minced chicken nugget with the sauce not applied as required. As a result of this failure, the resident choked on the food and required the Heimlich maneuver to clear the airway. The incident was documented in the nurse's progress notes, and subsequent evaluation showed no ill effects such as pneumonia or heart failure. Interviews with dietary staff and the DON confirmed that the meal was not prepared as ordered, and the dietary aide could not explain the deviation from the prescribed diet. The facility's policy required consistency with IDDSI guidelines, but this was not followed in this instance.