Failure to Supervise Dysphagic Resident and Ensure Safe Care, Resulting in Fatal Choking and Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and protection from accident hazards for residents with known swallowing difficulties and modified diets. One resident with dementia, prior stroke, dysphagia, and a physician-ordered mechanical soft diet with nectar thick liquids was repeatedly given regular-consistency foods and thin liquids by a family member. The medical record and therapy notes documented that the resident had a history of pocketing food, coughing, and choking with increased texture, and that speech therapy had specifically ordered a mechanical soft diet with nectar thick liquids, pureed fruit, no straws, and limited regular-consistency items. Staff, including the DON, ADON, speech therapist, and nursing staff, were aware that the family member frequently brought in foods such as cheeseburgers, fries, hard candy, beef stew, cheese puffs, and thin liquids that were inconsistent with the ordered diet. Despite this knowledge, the facility did not implement effective, documented interventions to manage the ongoing issue of the family bringing in unsafe foods. The care plan noted that the family brought in foods not conducive to the diet order and that the resident required supervision and assistance with meals, but it did not specify clear, actionable steps such as who to notify or how to respond when unsafe foods were provided. Interviews with the ADON, unit manager, DON, and therapy staff revealed that although they reported having multiple conversations with the family about choking risks, there were no corresponding progress notes or documented care plan meetings addressing these discussions or any formalized strategy. The physician and nurse practitioners reported they were not informed of the family’s noncompliance with diet orders and did not participate in discussions with the family about the risks, despite the resident being severely cognitively impaired and unable to understand the dangers of eating foods outside his prescribed diet. On the evening of the fatal incident, the resident had refused his ordered mechanically soft dinner tray. Later that night, the family member brought in a burger, chicken nuggets, french fries, and sweet tea with a straw and set the food up at the bedside. The assigned nurse informed the family member that the resident was on a mechanical soft diet with nectar thick liquids and should not have the meal due to choking risk, but the family member insisted he could eat a regular diet and left the food in front of the resident before exiting the facility. The nurse checked the resident shortly after, attempted to remove the food, but left it in place when the resident refused and did not thicken the tea. The nurse then left for break, instructing a nurse aide to check on the resident. When the aide went to the room, the resident was found pale, unresponsive, with food in his mouth and a partially eaten hamburger in his hand, and CPR and EMS were initiated but unsuccessful. EMS documentation indicated food and vomit in the airway and esophagus, and EMS believed the resident went into cardiac arrest after possibly choking on food. The facility also failed to provide safe incontinence care to another resident, who was rolled out of bed from an air mattress raised to the highest position, resulting in a forehead laceration and transfer to the emergency department. The second resident involved in the deficiency was receiving incontinence care on an air mattress that had been raised to its highest position. During the provision of care, staff rolled the resident, and the resident fell from the bed to the floor, striking the forehead. The fall resulted in a two-centimeter laceration to the left forehead, requiring transfer to the emergency department for treatment before the resident returned to the facility the same shift. This incident demonstrated that in addition to the lack of effective supervision and intervention for the resident with dysphagia, the facility also failed to ensure safe techniques and environmental controls during routine care activities, contributing to another avoidable accident.
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