Failure to Investigate Choking Incident as Possible Neglect
Penalty
Summary
The facility failed to follow its Abuse Prevention Policy requiring prompt and thorough investigation of all alleged violations involving abuse or neglect after a resident experienced a choking incident. The resident, who had multiple sclerosis, chronic pain, depression, and anxiety, was alert, oriented, able to understand and be understood, and was dependent on staff for all ADLs, including eating. The facility’s electronic charting system identified the resident as dependent on staff for meals. Nurse progress notes documented that during a dinner meal the resident began coughing, felt like food was stuck, had difficulty breathing, and was choking and vomiting food. The resident was assessed, the physician was notified, a chest X-ray was ordered, and the subsequent nurse note documented minimal right base atelectasis and an order for Augmentin for pneumonia. During a later interview, the resident reported that a CNA had been feeding the meal, that their head was too flat while being fed, that they said they could not do it, and that they subsequently developed pneumonia. The resident stated administration was aware of the incident and interviewed them the following day and was tearful about the event. When surveyors requested investigation documents and an incident report for the choking event, the DON stated no documentation had been completed. The facility’s Incident and Accident Log for the relevant month did not list the choking incident. The Medical Director stated the choking incident should have been investigated per facility policy, and the Nursing Home Administrator confirmed the facility failed to implement its policies and procedures to investigate this incident of possible neglect.
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