F0689

J

Failure to Supervise High-Risk Resident During Meal Leading to Choking Event

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

Penalty

Fine: $8,815

Summary

The deficiency involves the facility’s failure to provide adequate supervision during eating for a resident with known dysphagia and prior choking episodes. The resident was an older male with end-stage renal disease, bilateral lower extremity amputations, type II diabetes, dysphagia, severe cognitive impairment (BIMS 7/15), limited upper extremity range of motion, and dependence on others for most mobility. Records showed he required partial/moderate assistance with eating, had documented episodes of coughing and possible choking while being assisted with meals, and had a diet order for a regular diet with mechanical soft texture and thin liquids. Progress notes documented that the NP changed his diet to mechanical soft after a choking incident, requested a speech evaluation, and directed that he be monitored during meals for safety. The resident’s responsible party had requested that he be supervised during meals at all times due to prior choking incidents and concerns that he could not feed himself without staff assistance.

On the night of the incident, the resident had returned from dialysis and initially declined food. Later, the responsible party contacted the facility expressing concern that he had not eaten, and the nurse called the responsible party from the resident’s room on speakerphone so they could speak directly. The nurse informed the responsible party that the Dietary Manager would bring food and instructed the assigned CNA to assist the resident with the meal when it arrived. The Dietary Manager, who had just conducted an in-service on diet textures and customer service, spoke with the responsible party by phone and then went to the resident’s room, where she observed two untouched meal trays. The resident told her he was hungry and requested a turkey sandwich with cheese and mayonnaise. The Dietary Manager removed the old trays, told the resident she would bring the sandwich, and informed the CNA that the resident would need assistance with eating.

The Dietary Manager returned with the sandwich and a banana, placed the tray on the bedside table, and reported that it was not within the resident’s reach. She stated the resident requested a soda, and she told him she would get one and that the CNA would be in shortly to assist him with eating. Before she could return, she was diverted to another resident (her mother) who was complaining of chest pain, and she remained there while that resident was assessed and EMS was called. Video footage showed the nurse leaving the resident’s room, the Dietary Manager entering with a meal tray and leaving a few minutes later, and then no staff entering the resident’s room again until approximately 24 minutes later, when the CNA entered and found the resident unresponsive. The CNA observed food sliding from the side of his mouth, half of a sandwich in his hand, and a tray with the other half of the sandwich pushed away from the bed. EMS, already on-site for the other resident, responded and found the resident unresponsive, pulseless, and apneic with his airway completely obstructed by large amounts of emesis containing large white, creamy chunks that appeared to be food material. EMS suctioned food from the airway and vocal cords, initiated CPR and intubation, and transported the resident to the hospital, where he was later pronounced deceased. The facility did not have policies provided to surveyors that addressed supervision of residents during meals, and key staff, including the Administrator and some clinical leaders, stated they were not aware of prior choking incidents and believed it was safe to leave the resident alone with finger foods, despite documentation and family reports indicating a need for supervision during meals.