F0609

D

Failure to Timely Report Suspicious Death and Alleged Neglect Involving Choking and Cardiac Arrest

Missouri City, Texas Survey Completed on 03-09-2026

Penalty

Fine: $8,815

Summary

The deficiency involves the facility’s failure to timely report an alleged neglect-related incident and suspicious death to the State Agency within the required 2‑hour timeframe after an allegation or suspicion was formed. A male resident with end‑stage renal disease, bilateral lower extremity amputations, type II diabetes, dysphagia, impaired cognition (BIMS 7/15), reduced mobility, and need for assistance with personal care and eating was dependent on staff for transfers and required partial/moderate assistance with eating. His care plan and dietary assessments documented a mechanically altered, mechanical soft diet with thin liquids, monitoring for dysphagia signs (including choking), and staff assistance with eating due to weakness, dysphagia, and impaired cognition. An undated dashboard entry also instructed staff to assist the resident in eating due to inability to see. At a care plan meeting earlier in the month, the responsible party (RP) had voiced concerns that the resident was not being fed despite her ordering food, and the facility had indicated CNAs would attempt to feed him.

On the evening of the incident, the assigned LVN spoke with the RP, who asked about ordering food; the resident declined delivery, and the LVN told the RP that the Dietary Manager was preparing food for the resident. The LVN then informed the assigned CNA that the Dietary Manager was bringing food and that the resident would need assistance with eating. Video footage later showed the LVN entering and exiting the resident’s room, followed by the Dietary Manager entering with a meal tray and leaving a few minutes later, with no other staff entering the room for approximately 24 minutes until the CNA went in. The Dietary Manager reported that she had found two untouched trays earlier, that the resident requested a turkey sandwich with cheese and mayonnaise, and that she removed the old trays, prepared the sandwich, and returned with the sandwich and a banana. She stated she placed the tray on a bedside table near the door, out of the resident’s reach, told him she would get a soda, and informed him that the CNA would be in shortly to assist with eating, but she was then diverted to another resident (her mother) with chest pain and remained there while EMS responded.

When the CNA later entered the resident’s room to feed him, she observed a tray with half a sandwich pushed away from the bed, the other half of the sandwich in the resident’s hand, food sliding down the side of his mouth, and no response, respirations, or palpable pulse. Staff initiated CPR and EMS, who were already in the building for another resident, were brought to the room. EMS documented that the resident’s airway was completely obstructed by emesis, with large white, creamy chunks suctioned from the mouth, airway, and vocal cords, which EMS described as appearing to be food material, and EMS stated it was very likely the resident had been choking prior to cardiac arrest. Hospital records noted he arrived with CPR in progress and was later pronounced deceased. The RP reported to staff and EMS that she believed the resident had choked and expressed concerns about the staff’s response and the lack of supervision during eating, and EMS relayed to her that choking was suspected. Despite the RP’s expressed concerns, the resident’s known need for assistance with eating, the presence of food in his hand and mouth, and EMS’s findings of food‑like material obstructing the airway, the Administrator and DON concluded the resident had experienced cardiac arrest (or possibly pulmonary embolism), did not consider the death suspicious or neglect‑related, and determined the event was not reportable. As a result, the facility did not report the alleged neglect or suspicious death to the State Agency within the required 2‑hour timeframe, contrary to federal requirements and the facility’s own policy that all alleged violations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, be reported immediately within prescribed timeframes.