The facility failed to ensure that each resident received adequate supervision to prevent accidents when they allowed Resident 1, who had a history of quickly grabbing food and stuffing it into his mouth, causing a choking risk, to be seated in the dining room without adequate staff supervision while ambulatory and mobile residents were having snacks. The facility also failed to implement the same precautions during snack time as they did during meals for Resident 1. This was evidenced when Resident 1 obtained a cinnamon roll without staff knowledge and subsequently choked to death.
During an interview on 10/16/07 at 9:35 a.m., Staff A stated that on 10/14/07 at about 2:30 p.m., Staff G brought Resident 1 into the dining room after assisting him with a shower. She stated that 15 to 20 other residents were in the dining room while staff assisted them with snacks. Staff B gave Resident 1 a soda from the vending machine, and shortly thereafter noticed he was choking. Staff responded by performing the Heimlich maneuver, and obtained a "sticky bread-like substance" from Resident 1's mouth. Staff called 911. Resident 1 did not have a pulse and staff began CPR. Paramedics arrived and took over resuscitation efforts. Resident 1 was pronounced dead on the scene by paramedics at 3:04 p.m.
A review of Resident 1's record on 10/16/07 at 10:05 a.m., revealed that he was admitted to the facility on 7/31/98. His diagnoses included dementia with behavior disturbance. He was verbal, but often confused and disoriented. He used a wheelchair for mobility and required extensive assistance with most daily care needs. A nursing care plan originally dated 8/14/98 addressed his risk for choking, and was last updated on 9/8/07. It indicated Resident 1 presented a risk for choking because he had no teeth and refused to wear dentures, he overstuffed his mouth with food during meals, and had a history of choking. Under the heading "PLAN/INTERVENTION", the following approaches were listed: "serve with regular pureed diet extra portion, remind resident to take small bites and eat slowly, serve meals ahead with supervision, monitor at mealtime, invite/encourage to attend health education groups", and, "dental follow-up as scheduled". A social service note dated 10/2/07 indicates Resident 1 was seen by a dentist on that date, and that his dentures were relined, to be picked up the following day. A social service note dated 10/10/07 indicates, "Staff affixed FULD (full upper/lower dentures) to resident during mealtime. Resident refused to wear them." The care plan indicated that nursing staff was responsible for monitoring Resident 1 during meals. Although the care plan did not specify how soon Resident 1 was to be served before the other residents, later interviews with staff members revealed they would take him into the dining room for meals 30 minutes before other residents came in to eat, and would remain to supervise him until he finished eating.
During a phone interview on 10/16/07 at 10:45 a.m., Staff C stated she responded to a call for help in the dining room, performed the Heimlich maneuver on Resident 1, and "got a big chunk of food out". She said, "we don't know how he got any food". Staff C stated that Resident 1 was closely supervised and always seated about an arm's length from others, "because he tries to hit." She stated that Resident 1 had been given a soda, but that he had not yet been given a pureed snack. Staff C stated that no one was allowed to give him any other food or sit near him, and that food items were not left "sitting around" where he could reach them. She said that most of the facility's 34 residents were in the dining room when Resident 1 choked.
In an interview on 10/16/07 at 11:30 a.m., Staff D stated that he had worked at the facility for about ten years. He referred to Resident 1 as the facility's "number one high risk for choking" due to a history of stuffing large amounts of food in his mouth, and the fact that he had no teeth. He said that Resident 1 was fed 30 minutes before the other residents, and staff provided one to one supervision during meals to reduce his choking risk. Staff D said Resident 1 was not supervised as closely during snack time. He further stated that Resident 1 could tolerate a mechanical soft diet (food chopped and/or mashed) if fed slowly by staff, but if he fed himself independently he would put excessive amounts of food in his mouth, which increased his risk of choking. The physician had ordered a pureed diet for Resident 1 so that he could safely eat without physical assistance. Staff D stated that Resident 1 would take food if it was within his reach or sight. He said Resident 1 was purposely seated apart from other residents at snack time (staff brought him in for meals 30 minutes before any other residents came into the dining room) and given only a soda, but if he could he would take food from another resident. Staff D was not present during the choking incident.
On 10/16/07 at 12:00 p.m., Staff E stated in a phone interview that she was assisting residents in the dining room during snack time on 10/14/07. She heard Resident 1 yelling and cursing while being showered. Staff E stated she was not told when Resident 1 entered the dining room, and did not know he was in the room until he choked. She stated she did not recall whether other residents sat or walked near Resident 1 before he choked.
Further review of Resident 1's record on the afternoon of 10/16/07 revealed that there was no specific direction in the nursing care plan for supervision of Resident 1 during snack time, and that there was no reference to snacks at all.
In a phone interview on 10/16/07 at 12:55 p.m., Staff F stated that he took vital signs of other residents while in the dining room when he heard a call for help. He responded by performing the Heimlich maneuver on Resident 1 four or five times. He stated Resident 1's face was blue in color, and he coughed up a large amount of food. Staff F stated, "his mouth was full and he tried to cough but could not. The resident could not spit the food out. The nurse used the suction machine and fingers" to remove food from Resident 1's mouth. Staff F stated he was not aware that Resident 1 had come into the dining room, and did not notice he was there until he started choking. Staff F stated Resident 1 received a pureed diet with continuous supervision during meals, and was fed before the other residents came in to eat. Staff F had no idea how Resident 1 could have gotten any food, and did not notice whether any other residents were seated or walked near him before he choked.
On 10/16/07 at 2:05 p.m., in an interview with Staff G, she stated that after she gave Resident 1 a shower she took him in his wheelchair to the dining room. Two other staff were in the room and helped residents get snacks from the vending machine. Staff G did not exchange words with the other staff members before leaving the dining room, but stated, "they saw me". Staff G stated another resident sat in his wheelchair about three feet away from Resident 1, and two residents sat on the couch, but she could not recall who they were. She said she heard calls for help within five minutes after she left the dining room. Staff G stated that Resident 1 received a soda and pureed fruit only at snack time. She stated that Resident 1 ate his meals about 30 minutes before the other residents, taken into the dining room alone with one to one continuous staff supervision, "Because he would eat so fast - I have to remind him to slow down." She did not indicate that Resident 1 was to be monitored as closely during snack times.
On 10/16/07 at 2:40 p.m., Staff H was interviewed and stated she knew that Resident 1 had a history of stealing food and over-stuffing his mouth. She stated that Resident 1 was supervised during meals due to his risk of choking. She said staff was to make verbal contact with each other, saying, "(Resident 1's name) is here", to inform one another of Resident 1's whereabouts so they would know to supervise him.
In an interview on 10/16/07 at 3:00 p.m., Staff B stated that on 10/14/07 at about 2:30 p.m., she assisted the residents during snack time in the dining room. She stated that residents chose their snack items from the vending machine. She looked up at one point and noticed Resident 1 seated in his wheelchair in his usual spot near the television. She was not aware of him having been there before, and staff did not tell her that they had brought Resident 1 into the room. She gave him a soda. She looked up a few minutes later and saw he was pale with his head back, trying to cough and having difficulty breathing. Staff B called for help, and several staff responded. She stated the nurse did a finger sweep and obtained "a large mouthful of food" from Resident 1's mouth. Staff B did not see Resident 1 with any food in his hand when he choked. Staff B stated that another resident was seated about a foot away from Resident 1, but did not recall if any ambulatory residents were near him at the time. Staff B stated that Resident 1 always had one-to-one supervision during meals and ate his meals before any other residents came into the dining room
Staff A was interviewed on 10/16/07 at 3:15 p.m. When asked about Resident 1 having been brought into the dining room after his shower on 10/14/07, she stated, "There's always at least two staff in there to supervise the residents. They know to keep an eye on him. We haven't had any problems during snack time before." Staff A acknowledged that one-to-one supervision was not provided for Resident 1 during snack time, as it was during meals.
On 10/30/07 at 3:50 p.m., Staff J stated during a telephone interview that she was in the dining room during snack time on 10/14/07 when she heard a cry for help across the room. She responded by assisting another staff to perform the Heimlich maneuver, and obtained a mouthful of soft bread-like matter from Resident 1's mouth. She said she noticed a cinnamon roll wrapper on the table in front of Resident 1 next to his soda. Staff J stated she did not notice if any other residents were near Resident 1 before he choked, and had no idea who could have given him a cinnamon roll. She further stated that she asked the other residents later if anyone saw who gave Resident 1 the cinnamon roll and all responded, "no". Staff J said Resident 1 was usually closely supervised during snack time.
Staff A confirmed during interview on 10/16/07 at 3:15 p.m. that cinnamon buns are available in the vending machine in the dining room used during resident snack time.
On 4/15/08 at 8:20 a.m., a copy of the coroner's report dated 10/14/07 for Resident 1 was reviewed, and indicated, "the decedent.... was witnessed eating a cinnamon roll in the cafeteria of a care home facility shortly before becoming unresponsive and collapsing to the floor", and, "according to the paramedics, remnants of the cinnamon roll were suctioned from (Resident 1's) mouth". A concurrent review of Resident 1's autopsy report dated 10/16/07 indicated Resident 1's cause of death as, "asphyxia due to aspiration of food". The autopsy report also listed under the heading, "autopsy findings", "1. History of aspiration of food with food in airway.; 2. Food particles in each mainstem bronchus."
Therefore, the facility failed to ensure that each resident received adequate supervision to prevent accidents when they allowed Resident 1, who had a history of quickly grabbing food and stuffing it into his mouth, causing a choking risk, to be seated in the dining room without adequate staff supervision while ambulatory and mobile residents were having snacks. Staff were not made aware of Resident 1's presence when he was brought into the dining room during snack time the day he choked. Ambulatory residents and residents mobile in their wheelchairs were present in the dining room and in possession of food items from the vending machine that were not safe for Resident 1 to eat. Staff was not able to provide an explanation for Resident 1 gaining possession of a cinnamon roll, which was not a part of his ordered therapeutic diet. The facility also failed to include direction for staff supervision during snack time in Resident 1's nursing care plan, thereby neglecting to implement the same precautions during snack time as they did during meals for Resident 1. The facility was fully aware of Resident 1's high risk for choking and had implemented effective measures during breakfast, lunch, and dinner to ensure his safety while eating. The facility failed to address this risk as it pertained to snack times. This was evidenced when Resident 1 obtained a cinnamon roll without staff knowledge and subsequently choked to death.
This failure presented an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and was a direct proximate cause of the death of the resident.