F0689

J

Failure to Enforce Diet Orders and Visitor Food Policy Resulting in Fatal Choking Event

Peoria, Illinois Survey Completed on 12-22-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure adequate supervision and dietary management to prevent a choking incident for a cognitively impaired resident. The facility had a policy requiring visitors to notify nursing staff before providing outside food so staff could confirm consistency with the resident’s prescribed diet, allergies, and swallowing precautions. Despite this, the resident’s family member reported bringing food, including roast beef sandwiches and soda, to the resident weekly, and stated that staff were aware of this practice and never informed her that it conflicted with the resident’s diet. On the day of the choking event, the family member brought a roast beef sandwich from a fast-food restaurant, and an unknown nurse assisted her in carrying the food to the resident’s room, observed her placing sauce on the sandwich, and told the resident she would return, without addressing diet restrictions or stopping the food from being given.

The resident had been admitted with hospital discharge instructions specifying soft-to-digest foods, one-on-one feeding assistance, and aspiration precautions. However, the physician orders entered on admission documented a general diet with regular texture and consistency, and this order was never changed through the date of the resident’s death. The Director of Nursing later acknowledged that the resident was actually on a mechanical soft diet and that the diet order had been entered incorrectly on admission. The Dietary Manager stated that she had been informed the resident was on a mechanical soft diet and that the resident was served as such, but verified that the physician orders and care plan did not match what the resident was being served. The MDS and care plan from admission through death did not identify the resident as an aspiration risk, did not document a mechanical soft diet, did not indicate a need for staff observation while eating, and did not address the resident’s non-compliance with dietary restrictions or any education provided to the resident or family.

Nursing documentation from admission through the date of death contained no evidence that staff educated the family about the resident’s dietary needs, including permitted or prohibited foods related to swallowing precautions. Staff interviews confirmed that the family frequently brought snacks and fast food, and that the resident was known to eat and drink very quickly. A CNA reported that the resident had a bin of snacks in the room, including pretzels, prepackaged pastries, crackers, and soda, despite being on a mechanical soft diet. On the day of the incident, staff responded to a CNA’s call that the resident was choking and found the resident cyanotic, unresponsive, and with his mouth full of food. Staff attempted the Heimlich maneuver, performed repeated mouth checks, and initiated CPR until EMS arrived, but were unable to clear the airway. The family member present stated she knew the resident was on a mechanical soft diet but had not been told by staff that the roast beef sandwich conflicted with the resident’s diet, and also stated the resident had garbled speech and confusion and would not have been able to understand or communicate dietary restrictions.

The Care Plan Coordinator/MDS nurse stated she relied solely on the diet order in the computer and did not review the hospital discharge instructions, and she never spoke with the family about the resident’s diet. The Director of Nursing stated she never spoke with the family during the resident’s stay and was unaware that the aspiration risk and diet were not included in the care plan. These combined failures in accurately entering and reconciling diet orders, care planning for aspiration risk and supervision needs, enforcing the policy on food brought in by visitors, and educating the family about diet restrictions led to the resident being provided with food inconsistent with the prescribed mechanical soft diet and to the choking event that occurred while the resident was eating the roast beef sandwich brought in by the family member.

Removal Plan

• Initiated daily nursing huddles to review resident diets and identify residents requiring one-on-one supervision during meals.
• Notified all resident families of the facility policy on visitors bringing in outside food and each resident’s diet restrictions.
• Completed an audit of all residents’ diet orders by the Director of Nursing and Dietary Manager.
• Reviewed and verified all resident dietary cards by the Dietary Manager and Director of Nursing.
• In-serviced front desk personnel on handling delivered/outside food: stop family/delivery, notify nurse in charge, and nurse reviews food for consistency with diet orders/restrictions.
• Interdisciplinary Team reviewed and modified the policy on food brought in by visitors to address the new review process.
• Conducted mandatory all-staff training on the revised policy for food brought in by visitors and resident diets/restrictions; all staff in-serviced before start of next shift.
• Mailed a copy of the revised policy on food brought in by visitors to all resident responsible parties/families.
• Added the revised policy on food brought in by visitors to the new admission packet.