F0656

J

Failure to Care Plan and Supervise High-Risk Dysphagia Resident During Meal

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

Penalty

Fine: $8,815

Summary

The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes to address a resident’s dysphagia, history of choking, and need for assistance and supervision with eating. The resident was an older male with end-stage renal disease, bilateral lower extremity amputations, Type II diabetes, dysphagia, impaired cognition, reduced mobility, and dependence on dialysis. His records showed he required partial to moderate assistance with eating, had limited upper extremity range of motion, and was dependent for most mobility tasks. A prior progress note documented an episode of coughing and possible choking while being assisted with breakfast, after which the NP ordered a mechanical soft diet and a speech evaluation. The resident’s responsible party later requested that he be supervised during meals at all times due to choking concerns, and the NP requested monitoring during meals for safety.

Despite these documented issues, the resident’s care plan did not include a specific focus area for dysphagia, prior choking history, or the responsible party’s concern for monitoring during feeding. The care plan contained a general focus on potential nutritional problems and an ADL self-care deficit, with interventions such as monitoring for signs of dysphagia and providing partial/moderate assistance with eating, but it did not clearly identify the resident’s choking risk or the need for continuous supervision during meals. Staff interviews revealed inconsistent understanding of the resident’s needs: some staff believed he only required tray setup and could eat finger foods independently, while others reported routinely feeding him because he became weak or tired and could fall asleep while eating. The MDS Coordinator stated that if she had been aware of the resident’s choking history and active dysphagia diagnosis, these should have been reflected in the care plan with appropriate goals and interventions.

On the night of the incident, the dietary manager spoke with the responsible party, who was upset that the resident had not eaten after returning from dialysis. The dietary manager went to the resident’s room, observed two untouched trays, and the resident requested a turkey sandwich with cheese and mayonnaise. She removed the old trays, informed the assigned CNA that the resident would need assistance with eating, and later returned with the sandwich and a banana, placing the tray on the bedside table. She stated the tray was not within the resident’s reach and that she told him the CNA would be in shortly to assist. Video footage showed the dietary manager entering and leaving the resident’s room with a tray, and then no staff entering the room again until a CNA went in approximately 24 minutes later. When the CNA entered to feed him, she found the resident unresponsive, with food sliding from his mouth and half of a sandwich in his hand. EMS, already on-site for another resident, responded and documented that the resident’s airway was completely obstructed by large amounts of emesis containing large white, creamy chunks that appeared to be food material, which they suctioned from his mouth, airway, and vocal cords. The facility also failed to implement the existing care plan intervention for assistance with eating and monitoring for signs of dysphagia at this meal, as the resident was left alone with the sandwich and not continuously supervised while eating.