Failure to Supervise Resident with Dysphagia During Meals Resulting in Fatal Choking Incident
Penalty
Summary
A deficiency occurred when a resident with dysphagia, who was on a pureed diet and required close supervision during meals, was left unsupervised in the dining room. The resident had a history of cerebral infarction, hemiplegia, aphasia, and moderate cognitive impairment, and was known to be at risk for choking and aspiration. Care plans and physician orders specifically indicated the need for supervision during meals and noted the resident's tendency to take food from other residents' trays, as well as attempts to eat nonfood items. On the day of the incident, the resident finished his pureed meal and was able to self-propel his wheelchair across the dining area. Staff interviews revealed that the resident was known for quickly grabbing and consuming food not on his prescribed diet, particularly when unsupervised or while leaving the dining room. Multiple staff members acknowledged that there was no formal process or procedure in place to ensure the resident did not access inappropriate foods when exiting the dining area. Supervision was described as informal, relying on staff awareness and reminders to other residents not to leave food unattended. During the incident, staff were occupied with other duties and did not notice the resident's movements. The resident was later found in distress, choking on solid food items such as bread and hot dogs, which were not part of his prescribed diet. Despite immediate intervention by CNAs, an LPN, and EMTs, the resident was unable to be resuscitated and expired. Staff interviews confirmed that the lack of a structured supervision protocol contributed to the resident's ability to access and consume hazardous foods, leading to the fatal choking event.