F0689

J

Immediate Jeopardy from Unsecured Food Cart Access by Wandering Residents with Dysphagia

Mystic, Connecticut Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain a safe environment free from accident hazards and to provide adequate supervision to prevent accidents, specifically related to the storage and handling of food carts and leftover food. A food cart used for collecting dirty meal trays was routinely left overnight in the hallway outside a locked kitchen door, without a cover on the cart or on the attached garbage container. This cart, sometimes containing leftover food on plates or in an open garbage, was accessible to cognitively impaired residents with wandering behaviors and prescribed modified diets. The facility did not have a policy addressing food cart storage or proper disposal of food, and the process for securing the cart inside the kitchen was not consistently followed, despite the expectation that the supervising nurse would lock the cart in the kitchen.

Four residents with cognitive impairment, dysphagia, and/or wandering and elopement risk were identified as being affected by this unsafe practice. One resident had dementia, COPD, dysphagia, severe memory deficits, was dependent on staff for eating, and was on a regular pureed diet with thin liquids. This resident’s care plan and physician orders included a Wanderguard for wandering and elopement risk and interventions for wandering and nutrition, including a pureed diet and cues to eat slowly. Another resident had cerebral infarction, COPD, diabetes, severe memory deficits, and was on a low concentrated sweet, mechanical soft diet with thin liquids, with a Wanderguard and interventions for wandering and elopement. A third resident had dementia, diabetes, dysphagia, severe memory deficits, required set-up assistance for meals, and was on a low concentrated sweet, no added salt, mechanical soft diet with thin liquids, with a Wanderguard and interventions for wandering. A fourth resident had schizophrenia, anxiety, dysphagia, moderate memory deficits, was independent with eating and mobility, and was on a regular mechanical soft diet with thin liquids, with a Wanderguard and identified risk for choking due to poor dental hygiene.

The unsafe environment directly resulted in a choking episode for one resident. During an overnight shift, a nurse aide observed this resident, known to wander the halls at night looking for food and able to open unit double doors, at the food cart outside the locked kitchen door, choking after taking a piece of a peanut butter sandwich from the unattended cart. The LPN on duty performed the Heimlich maneuver, and the resident expelled the sandwich contents and returned to baseline. The nurse aide reported that the resident had previously attempted to take food from the dirty food cart on multiple occasions and had once taken a bite of a sandwich from the cart, but these incidents were not reported to licensed staff. The DON was aware the resident wandered and wore a Wanderguard but was not aware the resident was seeking food from the cart. The Director of Food Service and DON both acknowledged that the cart was not consistently locked in the kitchen, and the new RN supervisor on duty the night of the choking episode had not been trained on the meal tray collection process or the requirement to secure the cart, contributing to the failure to prevent access to the food cart and resulting in Immediate Jeopardy.

Additional information from interviews further supports the pattern of unsafe practice. The Director of Food Service described the standard process of using the cart to collect trays, scrape food into the attached garbage, and return the cart to the kitchen, and stated that when dietary staff left at night, an empty cart was left outside the locked kitchen for staff to return remaining dishes, with the expectation that food would be scraped into the open garbage. He reported having previously informed Administration that the cart was not being stored inside the locked kitchen. A dietary aide on the morning shift confirmed that his first task was to empty plates from the cart left in the hallway overnight and that sometimes food remained on plates and sometimes it had been scraped into the open garbage. The Building Specific Orientation Tour for the RN supervisor did not include training on meal tray collection or food cart storage. The facility’s existing policies on providing a safe and homelike environment and on elopements and wandering residents required a safe physical layout and systematic monitoring and management of residents at risk for wandering and elopement, but there was no specific policy addressing food cart storage or food disposal, and the failure to secure the cart and to communicate and act on known wandering and food-seeking behaviors led to the identified deficiency and Immediate Jeopardy.