F0689

J

Failure to Control Visitor Food and Supervise Resident on Pureed Diet Resulting in Choking Death

Los Angeles, California Survey Completed on 01-08-2026

Penalty

Fine: $9,430

Summary

The deficiency involves the facility’s failure to ensure a resident on a pureed gratification diet received food consistent with the ordered diet and to implement accident-prevention measures related to outside food brought by visitors. The resident had diagnoses including dysphagia oropharyngeal phase, dementia, prior pneumonitis due to inhalation of food and vomit, COPD, and required enteral feeding with only a pureed texture diet ordered for oral gratification. The resident’s care plan identified a risk for aspiration related to dysphagia but contained no nursing interventions addressing dysphagia, aspiration precautions, or the pureed diet. The Director of Nursing stated that each diagnosis required a specific care plan with interventions such as aspiration precautions, diet type, monitoring swallowing, and proper positioning, and acknowledged that this resident’s care plan did not include such interventions.

The facility also failed to implement and operationalize its policy on Foods Brought by Family/Visitors. The written policy required family and visitors to inform nursing staff when foods were brought for a resident and prohibited sharing such foods with other residents. The DON stated that staff were supposed to tell family and visitors to check with nurses when bringing food, but there was no documentation of licensed nurses checking outside food, no education given to visitors regarding outside food, and no signs posted for visitors about the policy or about not sharing food with other residents. A family member visitor reported that staff saw her bring food into the facility almost weekly for another resident and never said anything, and that staff did not explain any rules or policies on outside food or what foods were safe or unsafe.

On the day of the incident, a visitor brought chocolate chip and oatmeal cookies for the roommate of the resident on a pureed diet. While feeding a cookie to the roommate, the visitor reported that the resident on the pureed diet repeatedly asked for a cookie. The visitor then gave the resident a chocolate chip cookie without asking any staff if it was appropriate. After approximately five to ten minutes, the visitor observed the resident shaking, pale, and appearing to choke, and called for help. A CNA entered and found the resident in bed, unresponsive, pale, with food running from the mouth, and removed pieces of cookie from the mouth with a finger sweep. Additional staff, including a restorative nursing assistant, LVN, and respiratory therapist, responded and attempted the Heimlich maneuver, suctioning, and CPR. The resident was ultimately found to have no pulse and was later pronounced dead by paramedics. The facility’s failure to ensure supervision, environmental safeguards, and enforcement of the outside food policy allowed unsafe, non-pureed food to be provided to a resident with severe cognitive impairment and high aspiration risk, resulting in the resident receiving food inconsistent with the ordered pureed diet and choking.

Family interviews further showed that the resident’s responsible party was not informed of any policy for outside food or steps to prevent the resident from being fed unsafe food from outside. This family member stated there were no signs or measures in place to remind the resident not to eat or to tell others not to feed him, despite his poor memory and history of ingesting unsafe substances, including laundry detergent prior to admission. The DON confirmed that staff were informed of residents on aspiration precautions only verbally at morning huddles and that there were no posted signs for visitors regarding food brought by family or visitors. The medical director and registered dietitian both confirmed that the resident was ordered a pureed texture diet due to dysphagia and that only pureed foods should have been given, with the expectation that families would be educated and would not give food without consulting nurses. These combined failures in care planning, visitor education, supervision, and enforcement of the outside food policy led directly to the resident being given a regular-texture cookie, choking, and dying.

Removal Plan

• The Administrative Consultant educated the Administrator (ADM) and the Director of Nursing (DON) on the policy regarding Food Brought by Family/Visitors.
• The DON conducted in-services for all staff on the policy regarding Food Brought by Family/Visitors.
• A third-party software sent text and email messages to all residents and their responsible parties educating them to inform nursing staff when foods are brought to the facility for a resident and instructing them not to share/distribute food to other residents.
• The facility posted signage throughout the facility regarding the Food Brought by Family/Visitor policy.
• The receptionist or designee encouraged visitors to sign in on the Visitor Log and indicate whether they brought food/drinks; if food/drinks were brought, LVNs ensured the items were appropriate for the resident’s prescribed diet and educated visitors not to share food/drinks with other residents.
• The Registered Dietitian posted a Dietary Log outside the kitchen for staff to cross-check special requests from residents/staff/family to ensure requests follow physician dietary orders posted in the kitchen.
• The Interdisciplinary Team identified residents with mechanically altered diets and updated their care plans.