Failure to Assess and Intervene After Choking/Aspiration Event
Penalty
Summary
A resident with severe cognitive impairment, Down syndrome, gastroesophageal reflux disease, and sleep apnea experienced a choking and aspiration event during the evening meal. The resident began coughing and reportedly vomited while eating, which was observed by another resident who alerted nursing staff. Upon assessment, the LPN noted labored respirations and described the resident as choking, but did not perform a full clinical assessment such as checking lung sounds, vital signs, or oxygen saturation. The resident was assisted out of the dining area, encouraged to spit out sputum, and later taken to her room, where she continued to cough and struggle to clear her airway. Despite ongoing symptoms, including persistent coughing and difficulty swallowing, the LPN did not conduct further assessments or initiate emergency interventions. The resident was prepared for bed, placed on CPAP with supplemental oxygen, and left to sleep with her head of bed elevated. No documentation or evidence was found that the nurse monitored the resident's respiratory status or reassessed her condition after the initial event. The resident's condition deteriorated over several hours, with staff later finding her in significant respiratory distress, exhibiting audible crackles, cyanosis, and extremely low oxygen saturation. Multiple staff interviews confirmed that no vital signs, oxygen saturation, or lung assessments were performed by the LPN following the choking episode. The resident was not sent out for emergency care until she was found unresponsive and in severe distress several hours later. The lack of timely assessment and intervention following the aspiration event directly contributed to the resident's decline and subsequent death before emergency services could arrive.