Failure to Follow Ordered Pureed Diet Leads to Choking Incident
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician-ordered pureed diet with nectar-thick liquids for a resident with dysphagia, resulting in the resident being given an inappropriate snack texture. The resident had severe cognitive impairment with a BIMS score of 0, diagnoses including Alzheimer’s disease, delusional disorder, depression, restlessness and agitation, and was dependent on staff to ensure physician orders were followed. Nutritional assessments and physician orders documented that the resident was to receive a regular pureed (Level 1) diet with nectar-thickened liquids due to dysphagia and a history of coughing or choking during meals or when swallowing medications. Despite this, staff were aware of the resident’s ordered diet texture and fluid consistency through the Kardex, meal tickets, care plans, and diet orders. On the night of the incident, the resident was awake and walking in the main lobby when he stated he was hungry. A CNA had him sit at a table by the nurse’s station and obtained an Uncrustable sandwich from the kitchen refrigerator after asking an LPN what to get for a snack. The CNA reported that the LPN suggested the Uncrustable sandwich, while the LPN stated she was aware of the resident’s pureed diet with nectar-thick liquids and that the CNA had asked if it was okay, but she did not answer. Both the CNA and LPN acknowledged that the resident had been given Uncrustable sandwiches in the past without apparent problems, and the CNA knew the resident’s ordered diet was regular puree with nectar-thickened liquids. The Uncrustable sandwich is a mechanical soft texture food, not appropriate for a pureed diet as later confirmed by the speech language pathologist. After the resident took several bites of the Uncrustable sandwich, he set it down, stood up, and became unresponsive to verbal inquiry about choking. The CNA initiated back blows and called the LPN for assistance. The LPN immediately began the Heimlich maneuver while the resident was standing, then seated, and eventually on the floor where chest thrusts were performed. Food remnants from the sandwich were visualized in the resident’s mouth and removed by the CNA via finger sweep, with additional small remnants removed by the LPN. The resident subsequently produced phlegm, made noises, and was able to take sips of thickened liquid. Vital signs were obtained and he was monitored in a recliner near the nurse’s station. The incident was reported to the family, physician, hospice, and facility leadership, and both the CNA and LPN were suspended pending investigation for not providing the correct diet texture. The facility’s pureed diet policy specified that foods must be pureed to a smooth, lump-free, extremely thick consistency and that transitional foods are not allowed unless assessed and ordered by an SLP or physician, underscoring that the Uncrustable sandwich did not meet the ordered diet requirements.
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