Failure to Develop and Implement Individualized Care Plan for Dietary Needs Resulting in Resident Death
Penalty
Summary
The facility failed to develop and implement a comprehensive, individualized care plan that accurately reflected the nutritional and dietary needs of a resident with a history of swallowing disorders. The resident had previously experienced choking incidents and had been evaluated by a Speech-Language Pathologist (SLP), who recommended a pureed diet with nectar thick liquids and specifically advised against peanut butter sandwiches. Despite these recommendations and physician orders, the resident's care plan did not include specific interventions to ensure that all snacks provided, including those outside of scheduled meals, met the prescribed therapeutic diet. On the day of the incident, a Certified Nurse Aide (CNA) provided the resident with a peanut butter sandwich at the resident's request, despite being aware of the pureed diet order. The CNA had previously observed the resident eating peanut butter sandwiches without difficulty and did not verify the current diet order through available resources such as the KARDEX, electronic medical record, or by consulting a nurse. The resident choked on the sandwich, became unresponsive, and later died at the hospital. The official cause of death was determined to be choking on a food bolus. Interviews with staff revealed a lack of clarity and consistency in care planning and implementation. The care plan did not incorporate the SLP's or dietary manager's recommendations, and there was no policy or standard provided regarding acceptable food items for different therapeutic diets. Staff members were aware of the resident's dietary restrictions, but the absence of clear, individualized interventions in the care plan contributed to the provision of an unsafe snack, resulting in the resident's death.
Removal Plan
- The Dietary Manager labeled all snacks/snack-room foods with correct consistency per residents' diet orders.
- The DON, ADON, and SDC educated all licensed nurses, CMTs, and CNAs regarding: Reviewing the care plan, KARDEX, and diet orders before providing snacks; IDDSI standards for puree and mechanical soft diets; Specific instruction that peanut butter was not allowed for puree diets unless blended with another food to meet puree consistency.
- Staff completed return demonstrations and will not work unsupervised until competency verified.
- Care plans for all residents on modified diets were reviewed and updated by licensed staff to include: Speech therapist and dietary recommendations; Specific snack and supplemental food interventions; Cross-reference to diet order consistency requirements.
- Administrator initiated ongoing daily audits of snacks and care plans to ensure compliance.
- New staff will be educated during orientation and before working independently.