F0726

D

Failure to Ensure Staff Awareness of Prescribed Diet and Reporting of Unsafe Eating Behaviors

Mystic, Connecticut Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure nursing staff were aware of a cognitively impaired resident’s prescribed pureed diet and to report and address unsafe eating behaviors. The resident had dementia, COPD, dysphagia, severe memory deficits (BIMS score of 2), was dependent on staff for eating, and had care plan interventions for a regular, pureed diet with thin liquids, cues to eat slowly, remaining upright after meals, and snacks between meals and at bedtime. The resident was also care planned and ordered for a Wanderguard due to wandering and elopement risk. Despite these orders and care plan interventions, the resident was able to access a food cart located outside the locked kitchen door and obtain a peanut butter sandwich that was inconsistent with the prescribed pureed diet.

On the night of the incident, the resident wandered in the hallway and took a piece of a peanut butter sandwich from the food cart, then began choking. NA #1 observed the resident at the food cart choking and alerted LPN #1, who performed the Heimlich maneuver and the resident expelled the sandwich contents. NA #1 reported that the resident habitually wandered the hallway during the night looking for food, had previously attempted to take food from the dirty food cart, and had been seen taking a bite of a sandwich from the cart, but these prior incidents were not reported to licensed staff because NA #1 believed staff were already aware. NA #1 was not aware the resident was on a pureed diet and had been giving the resident snacks such as chocolate pudding at night. The DON stated she was unaware of the prior sandwich incident and confirmed that NA #1 had not reported the resident’s attempts to take or eat food from the food cart and that such incidents should have been reported to a licensed nurse.