Failure to Provide Prescribed Diet Texture Results in Resident Choking and Hospitalization
Penalty
Summary
The facility failed to provide food in the proper consistency as ordered by the physician for a resident with a history of stroke and swallowing difficulties. The resident was prescribed a mechanically altered diet, later changed to a pureed texture, but was served food items inconsistent with these orders on multiple occasions. On one occasion, the resident was served a piece of chicken that was not ground as required, leading to a choking incident that resulted in hypoxia, aspiration, and hospital admission. Documentation shows that the nurse aide delivered the meal tray without verifying the correct diet texture, and the resident's husband had to cut the chicken into small pieces before the resident began choking. Subsequently, the resident experienced another choking episode after being served Brussel sprouts, which are not permitted on a mechanical soft diet due to their tough texture. Despite recent staff education on appropriate diet modifications, the dietary manager confirmed that Brussel sprouts were served to the resident, contrary to guidelines. The resident reported that these incidents were frightening and that she avoids certain foods due to a history of choking. These events demonstrate a failure by both dietary and nursing staff to ensure that prescribed diet textures were consistently provided, resulting in significant adverse outcomes for the resident.