Failure to Report Resident Choking Death as Possible Neglect
Penalty
Summary
The deficiency involves the facility’s failure to report a possible situation of neglect to the State survey agency after a resident choked during a meal and subsequently died. The resident had diagnoses including malignant neoplasm of the prostate and obesity, was cognitively intact, and required only setup or cleanup assistance with eating. He was on a regular diet with regular texture and thin liquids, had no documented history of coughing or choking with meals or medications, and was not receiving speech therapy. His care plans addressed risk for altered nutritional status and noted that he was edentulous, with interventions including providing meals per preference and order and assistance with meals as needed. On the day of the incident, documentation showed that a CNA delivered the resident’s lunch tray while he was sitting upright with no concerns noted. Shortly thereafter, another CNA brought a visitor into the room and again no concerns were noted. When a CNA later returned to the room to pick up trays, the resident was observed sitting upright with his face turning blue, pointing and pounding on his throat/chest area, and showing signs of choking. Staff immediately called for help and initiated back thrusts, followed by the Heimlich maneuver performed by nursing staff after verifying the resident’s DNR Comfort Care Arrest status. Despite continued efforts, the obstruction could not be visualized or dislodged, EMS was called, and the resident was ultimately pronounced deceased. Witness statements indicated the resident had been eating blueberries and yogurt brought by family, in addition to chicken from his lunch tray. The facility completed an internal incident report and collected multiple witness statements, including from the CNAs and nurses involved. The Administrator later acknowledged that no self-reporting incident was submitted to the State survey agency regarding this choking event and resulting death. The Administrator questioned whether reporting was required since the facility’s internal investigation concluded there was no wrongdoing and staff responded appropriately. However, he recognized that the event was an unusual occurrence resulting in a resident’s death that should have been reported as possible neglect, consistent with the facility’s abuse, neglect, and exploitation policy, which requires immediate reporting of alleged violations and events that could indicate noncompliance related to neglect, including those resulting in serious bodily injury.
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