Failure to Provide Prescribed Diet Results in Fatal Choking Incident
Penalty
Summary
A resident with a history of schizophrenia, diabetes, major depression, obsessive-compulsive personality disorder, and lung disease was assessed as having mild cognitive impairment and required moderate assistance with eating. The resident was on a prescribed Level 1 Dysphagia pureed diet, which required smooth, pudding-like food textures to prevent choking. There were no prior issues with choking while the resident was maintained on this diet. On the day of the incident, a registered nurse assisted the resident in purchasing a sticky bun from a vending machine, despite the resident's dietary restrictions. The nurse did not consider the resident's ordered diet at the time of the purchase. After receiving the sticky bun, the resident began eating it in the dining room, subsequently started to choke, became unresponsive, and fell from his chair. Staff initiated CPR and emergency services were called. Food was found lodged in the resident's throat and was removed during resuscitation efforts. The resident was transported to the hospital, where he was found to have suffered a witnessed aspiration event, cardiac arrest, cervical and rib fractures, anoxic brain injury, and seizure activity. He was later placed on comfort care and pronounced brain dead. The failure to adhere to the prescribed pureed diet and the provision of an inappropriate food item directly led to the choking incident and subsequent fatal outcome.
Removal Plan
- Vending machines were locked in the conference room.
- No staff would assist a resident to get food out of the vending machine.
- If a resident requested an item against his prescribed diet orders, staff would notify the charge nurse, offer a safe snack, and always verify the diet before offering food or drink.
- All snacks for residents must be approved by the dietician and come from dietary services.
- Facility policy updated to require staff to check resident's code status prior to performing CPR, initiate CPR if full code, call 911, and remove visible obstruction during every pulse check.
- Staff are re-educated on choking procedures annually.
- Nursing and dietary staff receive additional training regarding the different types of mechanical soft diets, where to find a resident's diet type, and feeding assistance/aspiration prevention techniques.
- DON completed random diet order checks for ten residents twice a week.