Resident Provided Incorrect Diet Texture Resulting in Choking and Hospitalization
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including dysphagia and a history of stroke, was not provided food in the correct texture as ordered by the physician. The resident was on a regular diet with minced and moist texture due to aspiration risk, as documented in the care plan and physician orders. Despite these orders, a social worker, who typically does not prepare or serve meals, provided the resident with a regular texture meal without verifying the diet order. Shortly after receiving the incorrect meal, the resident was found unresponsive and not breathing by a certified nursing assistant (CNA) who was bringing the correct diet plate. The CNA immediately called for assistance, and a nurse assessed the resident, finding evidence of choking on food. The nurse and CNA worked to clear the airway, and when no pulse was found, cardiopulmonary resuscitation (CPR) was initiated until emergency medical services arrived. The resident was subsequently hospitalized, intubated, and diagnosed with cardiac arrest and pneumonitis due to inhalation of food and vomit. Interviews with staff confirmed that the social worker did not check the resident's diet order before serving the meal, and the CNA was unaware the resident had already been served. The facility's policy specified the requirements for a minced and moist diet, which were not followed in this instance. No other residents were reported to have received the wrong diet texture during the same meal event.