Failure to Follow Physician Diet Orders Results in Fatal Choking Incident
Penalty
Summary
A resident with a history of choking and aspiration risk, who was on an assist to dine program and had physician orders for a mechanical soft diet, was served a regular diet tray containing pork loin. The dietary staff had determined that the pork loin was not suitable for mechanical soft diets and had substituted pimento cheese sandwiches for residents requiring this diet. However, due to a miscommunication and error during meal service, the resident received the regular pork loin tray instead of the intended mechanical soft substitution. The resident began choking while eating the meal and became unresponsive, ceasing to breathe. Staff initiated the Heimlich maneuver and CPR, and emergency services were called. Despite these efforts, the resident was transported to the hospital and later expired. The cause of death was determined to be food aspiration leading to respiratory failure and hypoxia. Interviews with staff revealed that the error occurred when the dietary staff and LPN misidentified the correct tray for the resident, resulting in the resident being served food inconsistent with the prescribed mechanical soft diet. Facility policies required that all residents be provided with the prescribed diet as ordered by the physician, and that staff verify the correct tray and diet before serving. In this incident, these procedures were not followed, as the resident's tray was not properly checked against the diet order, and the substitution intended for mechanical soft diets was not provided. The failure to follow physician orders and facility policy directly led to the resident receiving an inappropriate meal, resulting in a fatal choking incident.
Removal Plan
- Education on diet policy, supervision of dining rooms, and preparation of therapeutic diets.
- The facility uses pictures of all three meals showing therapeutic diet consistencies which are sent to and approved by the dietary manager prior to serving any meals.
- Dietary staff send a menu to all units showing alternatives for all regular and mechanically altered diets.
- All food substitutions are approved by the dietary manager.
- The facility holds daily briefings regarding diets/meals between the dietary manager and charge nurse/Director of Nursing (DON).
- Menus are sent to all units and posted on each unit, followed by documented communication from charge nurse/DON to floor staff of any changes.
- The facility reviews all resident diagnoses, diet orders, and aspiration risk.