Improper Preparation of Potato Au Gratin Leading to Choking Incident
Penalty
Summary
The deficiency involves the facility’s failure to prepare potato au gratin according to the standardized recipe and to ensure the potatoes were cooked to a tender consistency before service. The facility’s Fall/Winter menu listed potato au gratin for the dinner meal, and the kitchen production report for that meal contained no documented temperatures to verify that the food items were cooked thoroughly. The facility’s standardized recipe for potato au gratin required potatoes to be peeled, sliced, boiled or steamed until softened, then baked until tender and soft enough to break apart with a fork. The Dietary Manager stated that the potatoes should be soft after baking and easily broken with a fork, but acknowledged that the cook responsible for the meal left the facility and did not participate in an interview. One resident with cerebrovascular disease, aphasia, dysphagia, and hemiplegia had a care plan identifying swallowing problems and interventions such as staff education on special dietary and safety needs, upright positioning, slow eating, and thorough chewing. This resident had a physician order for a regular diet under an AMA agreement despite the dysphagia. On the evening in question, the resident choked while eating potato au gratin in the main dining room. Nursing documentation described the resident turning blue, having difficulty breathing with no notable breaths, and requiring multiple abdominal thrusts (Heimlich maneuver) before expelling a large, hard piece of potato that could not be cut with a fork. A subsequent health status note recorded that the resident declined hospital transfer and that a STAT chest X-ray was ordered. Two other cognitively intact residents reported that the potatoes served at that meal were hard and not tender. One resident stated the potatoes were “hard like they were still raw” and reported this to staff but said nothing was done to correct the issue. Another resident, who had a care plan for nutritional risk and monitoring for dysphagia signs, stated she was present when the choking incident occurred and observed the affected resident place a large piece of potato in his mouth. She reported that the potatoes were “not so good” and “not tender,” and commented that sometimes the food is cooked well and sometimes it is not. These resident interviews, combined with the lack of documented cooking temperatures and the description of the expelled potato piece as hard and not cuttable with a fork, demonstrate that the potatoes were not prepared and cooked according to the facility’s standardized recipe and menu requirements.
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