Failure to Provide Appropriately Prepared Food for Resident with Chewing Difficulties
Penalty
Summary
The facility failed to ensure that food was prepared in a form appropriate to meet the needs of a resident with chewing difficulties, resulting in a choking incident. The resident had a documented history of vascular parkinsonism, dementia, anxiety, depression, dysphagia, and cognitive communication deficit. Orders and care plans indicated the resident required a mechanical soft diet, with specific recommendations for ground ham according to the facility's dietary spreadsheet. However, the resident was served diced ham instead of ground ham during a meal, which did not align with the individualized dietary needs outlined for mechanical soft diets. During the meal, the resident began to choke on the diced ham, exhibiting signs of distress such as gurgling sounds, blue lips, and inability to cough up the food. A CNA responded by performing the Heimlich maneuver, after which the resident expelled the food and was able to breathe and speak again. Staff interviews revealed uncertainty and inconsistency regarding the appropriate texture for mechanical soft diets, with some staff believing diced ham was acceptable based on past guidance, despite the dietary spreadsheet specifying ground ham for this diet type. Further review of facility policies and interviews with dietary and clinical staff highlighted a lack of clarity and adherence to individualized dietary modifications. The facility's own policy required that mechanically altered diets be individualized and that staff follow the dietary spreadsheets, which in this case specified ground ham. Despite this, diced ham was served, and staff were not uniformly aware of the specific requirements for the resident's diet, directly leading to the choking incident.