F0684

D

Delayed Swallow Evaluation After Choking Episode in Resident With Dysphagia

Jerseyville, Illinois Survey Completed on 01-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to timely evaluate the swallowing function of a resident with known dysphagia after a choking episode. The resident was admitted with diagnoses including Alzheimer’s disease, cerebral infarction, and dysphagia, and the MDS documented severe cognitive impairment, need for setup or clean-up assistance with eating, a mechanically altered therapeutic diet, food holding in the mouth/cheeks, and coughing or choking during meals or when swallowing medications. The care plan identified dysphagia with increased risk of aspiration, choking, and swallowing difficulties, and the diet order specified a mechanical soft diet. During a noon meal, the resident experienced an episode in which a piece of bread became lodged in the throat; by the time the LPN arrived in response to staff notification, the resident had already expelled the bread.

Following this choking event, a physician order was written for speech therapy to evaluate and treat as indicated, and the SLP reported that the LPN had made a referral for a swallow evaluation after the episode. However, the SLP stated that the evaluation had not yet been completed and was only planned for sometime later in the week, and the DON was unsure how soon residents should be evaluated after choking. The medical director stated awareness of the choking incident and was unsure why it took the SLP so long to evaluate, noting that such evaluations are normally done the next day. The resident’s swallowing function was ultimately evaluated 11 days after the choking episode. The facility’s Therapy Evaluation/Reassessment Policy did not specify a timeframe for conducting a speech therapy evaluation following a referral for choking.