Failure to Follow NPO and Thickened Liquid Orders Resulting in Choking Episode
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s order for a resident who was ordered nothing by mouth (NPO). A resident with cerebral palsy and autism, who had a PEG tube and an NPO order dated 04/21/25, was given a cola by a staff member who was not familiar with the resident. The resident, who had been determined incapacitated on 04/21/25 and had a BIMS score of 9 indicating moderate cognitive impairment, requested the cola, took a drink, and immediately coughed. Nursing documentation noted that the resident was aware of her NPO status but still requested the cola, and that the cola was removed after the choking episode and the resident was taken to the nurse for assessment. The incident was documented in nursing notes as a choking episode that occurred during activities when the resident was in the dining room post-activity, before the noon meal. Record review also showed that several other residents in the facility had orders for specialized liquid consistencies, including nectar thick liquids and honey thick liquids. The facility acknowledged that a CNA provided the soft drink without checking the Kardex and diet orders. Interviews conducted later with various staff members, including dietary, nursing assistants, activities, therapy, environmental services, maintenance, and administration, revealed that staff could verbalize the need to verify a resident’s diet or refer the request to nursing before providing food or drink. However, the documentation provided from prior staff trainings did not specifically address the requirement to follow physician orders and to check those orders before giving residents any food or liquids.
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