On 11/30/08, a resident suffocated when food became stuck in his windpipe during lunch. He began coughing and slumped over in his wheelchair. Staff members reported performing CPR and the Heimlich maneuver on the resident, who died shortly after paramedics arrived. An autopsy found that the cause of death was asphyxia due to aspiration of food. Although the resident had recently been discharged from the hospital with dietary orders for "aspiration precautions," the facility had served him a lunch of beef with barbecue sauce, mashed potatoes and steamed cabbage and carrots. Twice in November, dietary and nursing staff found that he was having difficulty swallowing thin liquids but did not alert his doctor or alter his diet and care plan accordingly. These failures led to his death.