Failure to Supervise Resident with Dysphagia Leads to Fatal Choking Incident
Summary
The facility failed to provide necessary supervision and assistance with Activities of Daily Living (ADL) care during meals for a resident diagnosed with dysphagia, which ultimately led to the resident's death by choking on a sandwich. The resident, a male with a complex medical history including cerebral palsy, functional quadriplegia, and dysphagia, required total dependence for ADL care and was non-verbal. Despite these needs, the resident was left unsupervised with a meal for 32 minutes, contrary to the prescribed one-on-one assistance during meals to prevent choking or aspiration. The resident's care plan was not updated to reflect the need for one-on-one assistance during meals, despite clear indications from the Speech Therapy Transitional Evaluation and Plan of Treatment that such supervision was necessary. The facility's policies on ADL and meal assistance were not adhered to, as the resident was left to consume a meal independently without the required supervision. This oversight was compounded by a lack of communication and coordination among staff, as evidenced by the CNA's decision to leave the resident's meal tray in the room without ensuring the resident was fed. Interviews with facility staff revealed a breakdown in the implementation of care plans and supervision protocols. The CNA assigned to feed the resident did not complete the task due to shift timing issues, and the subsequent CNA did not arrive in time to prevent the incident. The facility's Director of Nursing acknowledged gaps in the care planning process, citing frequent changes in ownership and leadership as contributing factors to the oversight. The failure to provide adequate supervision and assistance during meals directly resulted in the resident's death by choking.
Removal Plan
- The Regional Director of Operations and the Administrator reviewed the dining assistance policies to ensure alliance with CMS/State regulation.
- The Administrator, DON, and the Regional Director of Clinical Operation conducted mandatory retraining for nurses on supervision of ADL care including feeding/dining assistance assignments.
- The DON and/or Administrator retrained nursing staff that ADL care/meal assistance must continue uninterrupted and cannot be halted or delayed due to a shift change.
- The Administrator and DON assessed staffing levels during meal service to ensure adequate assistance.
- An emergency Quality Assurance and Performance Improvement Ad Hoc meeting was conducted with the Administrator, DON, RDO, RDCO, and Medical Director to review the removal plan and root cause analysis.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with moderate cognitive impairment and a history of stroke was repeatedly observed over several days in visibly soiled clothing and bedding, with a strong urine odor, despite stating multiple times that he had requested assistance with changing and hygiene. Documentation indicated he was independent with toileting and personal hygiene and only occasionally incontinent, but his care plan lacked detail on the level of assistance needed, while an LPN reported he actually required staff help with bathing, grooming, toileting, and care. Laundry practices involved leaving clean, labeled clothing bagged in the linen room for nursing staff to distribute rather than returning it directly to rooms, and the DON reported that staff were expected to round every two hours and as needed to keep residents clean and dry, although there were no written ADL or resident care policies in place.
Failure to provide scheduled bathing and grooming assistance: Two residents with intact cognition and ADL dependence did not receive bathing as documented on a weekly schedule, and one resident also had unaddressed facial hair and greasy, unkempt hair. Records did not show consistent weekly baths, additional refusals, or reasons for missed care, and staff interviews confirmed residents were expected to receive at least weekly bathing unless they refused and that facial hair should be shaved when noticed.
Failure to provide restorative ambulation and respond to a decline in mobility: A resident with dementia, weakness, chronic pain, and limited physical mobility was care planned for daily ambulation with a FWW and staff assist of 1, but the rehab record repeatedly showed ambulation as not applicable and staff interviews confirmed the task was often not done. The resident stated she could no longer walk, staff reported she had not walked for weeks and now required a sit-to-stand lift with assist of 2 for transfers, and the chart lacked an ADL decline assessment or revision of the ambulation care plan.
Failure to provide personal hygiene care: A resident with severe cognitive impairment, Parkinsonism, and ADL dependence was documented as refusing showers, nail care, and shaving, but the record lacked evidence that staff re-approached or rescheduled care. Observations showed oily hair, long jagged nails, and unshaven facial hair, and staff confirmed the resident needed assistance and had not had a shower for weeks.
Failure to provide routine nail care. A resident with severe cognitive impairment who was dependent on staff for personal hygiene was supposed to receive weekly bath and nail care per the care plan, but the EMR did not show it was provided. Staff observed long fingernails extending past the fingertips with dark matter under the nails, and later the nails remained unchanged with part of a fingernail broken off. An LPN confirmed the nails should have been completed the prior week, and an RN stated the condition was unacceptable.
Two residents who required staff assistance with ADLs did not receive showers and hair washing as care-planned and expected. One resident with dementia and cervical spine conditions was observed with flaky skin and greasy hair, and the family’s shower calendar showed only four showers in a month despite an expectation of three per week, with no refusals documented in the record or care plan. Another cognitively intact resident with quadriplegia and spinal stenosis reported rarely receiving scheduled showers, and was observed with long, greasy hair, again with no refusals documented. The DON and Administrator acknowledged CNAs believed they could not provide baths without a dedicated bath team and historically had no room assignments, despite facility policy requiring provision and documentation of ADL care and refusals.
Failure to Provide Timely ADL and Hygiene Care to a Dependent Resident
Penalty
Summary
Surveyors found that the facility failed to provide necessary ADL care, including grooming and hygiene, to a dependent resident over multiple days. The resident was repeatedly observed in visibly soiled clothing with a strong odor of urine, first standing in his doorway holding onto a wheelchair with wet navy pants saturated down to his calves, stating he had been waiting for staff to change his clothes. More than an hour later the same day, he remained in the same soiled pants and shirt while seated in a wheelchair near the nurses’ station. The following day, he was again observed wearing the same soiled clothes, smelling of urine, with his shirt stained with food and a dark liquid. His room had a strong urine odor, his bed was soiled with urine, and only two pairs of pants were seen on a chair with no other clothing available in the room. On a subsequent observation, he was seated on the edge of his bed wearing different pants and no shirt, with yellow-stained sheets beneath him and his previously soiled clothes on the floor; he reported that he had requested assistance but no staff had come, so he changed himself. Record review showed the resident had a history of stroke and repeated unspecified conditions, with a recent Quarterly MDS indicating moderate cognitive impairment (BIMS score of 10). The MDS documented him as independent for toileting, showering, personal hygiene, and related ADLs, and only occasionally incontinent, but his care plan did not specify the level of assistance he required for incontinence care and other ADLs. In contrast, an LPN familiar with the resident stated he required staff assistance with bathing, grooming, toileting, and care, and that he did not refuse such assistance and appropriately requested help. The LPN also explained that personal clothing was laundered at the facility and left bagged in the linen room for nursing staff to distribute, rather than being returned directly to resident rooms. The DON stated that staff were expected to follow best practices, including rounding every two hours and as needed to keep residents clean and dry, and acknowledged that all residents required some level of assistance with ADLs. The DON further stated the facility had no written ADL, resident care, or quality of care policies, despite these expectations.
Failure to Provide Scheduled Bathing and Grooming Assistance
Penalty
Summary
The facility failed to ensure that two residents who required assistance with activities of daily living received routine bathing and grooming services needed to maintain personal hygiene and dignity. R2’s MDS identified intact cognition and a need for ADL assistance, and the care plan directed staff to assist with dressing, grooming, bathing, and oral care while honoring personal hygiene preferences. R21’s MDS also identified intact cognition and a need for ADL assistance, and the care plan directed staff to assist with dressing, grooming, bathing, and oral care. R2’s bathing record showed a weekly bathing schedule, but the documentation did not show bathing was completed every week as scheduled. Baths were documented on several dates, but the time between some baths exceeded one week, and the record did not show additional refusals or reasons why scheduled baths were missed. During observation, R2’s hair was messy and greasy, and long white chin hairs were present. R2 stated she did not get baths very often because the facility was short staffed and said she did not have access to tweezers, a shaver, or a mirror. The EMR did not document that grooming assistance had been offered or provided for facial hair care. R21’s bathing record also showed a weekly bathing schedule, but the documentation did not show bathing was completed every week as scheduled. The record showed one refusal and several baths, but some intervals between baths exceeded one week, and there was no documentation of additional refusals or reasons for missed baths. R21 stated she had been in the facility since mid-April and had yet to have a bath or shower, and said staff were waiting for physician approval because of wounds, though that had been a while. R21 also stated she had only had her hair washed once with a shampoo shower cap while in bed. Staff interviews confirmed residents were expected to receive at least one bath weekly unless they refused, refusals should be documented, and facial hair should be addressed when noticed.
Failure to Provide Restorative Ambulation and Address Decline in Mobility
Penalty
Summary
The facility failed to provide restorative ambulation services and failed to respond to a decline in ambulation status for one resident who had mild cognitive impairment, dementia, hypertension, diabetes, weakness, and chronic pain. The resident’s care plan and restorative documentation directed daily ambulation with a front wheeled walker and staff assistance of one, and the resident was also identified as having limited physical mobility and being at risk for falls due to weakness, chronic pain, and an unsteadied gait and balance. However, the nursing rehab point-of-care record repeatedly documented ambulation as “not applicable,” with only one entry showing the resident ambulated for 15 minutes and one entry showing refusal. The resident stated she could no longer walk and that staff needed to help her get into bed and her wheelchair. Staff interviews confirmed the ambulation task was not being completed. A nursing assistant stated aides were responsible for ambulation but were not completing it, and another nursing assistant stated ambulation was supposed to be done but was not done very often; that staff documented it as not applicable when it did not get done; and that the resident had not walked at all for several weeks and was using a sit-to-stand lift with assist of two for all transfers. An RN stated the task just did not get done and that no plan had been created to fix it. The DON stated the resident’s condition had changed and a therapy evaluation should have been requested, and also stated the care plan needed revision because the resident would not be transferred with an assist of one. The resident’s medical record lacked an assessment for ADL decline, including any revision to the ambulation care plan.
Failure to Provide Personal Hygiene Care
Penalty
Summary
The facility failed to provide personal hygiene care for one dependent resident who was unable to complete activities of daily living without staff assistance. The resident’s MDS indicated severe cognitive impairment, verbal behaviors, refusal of bathing, and need for assistance with toileting, dressing, shoes, and personal hygiene. The care plan identified a potential alteration in completion of ADLs related to Parkinson’s disease and directed staff to assist with bathing, grooming, and lower body dressing. The Kardex also indicated the resident needed assistance of one with bathing, grooming, and personal hygiene. Weekly skin checks showed the resident had a shower on 4/7/26, but then refused showers, nail care, and shaving on 4/14/26, 4/21/26, and 5/5/26. The medical record lacked documentation of attempts to re-approach or reschedule the showers. During observations, the resident had oily, dull hair, overgrown facial hair, and fingernails that were uneven, jagged, long, and untrimmed. A NA confirmed the resident had dirty hair and long nails and stated he needed to be shaved. An RN stated the resident’s behavior varied, that he needed supervision and verbal redirection, and verified there had been no shower since 4/7/26. The DON and ADON stated staff were expected to re-approach residents, try a different person or time for the shower, and that showers, nail care, and shaving were important for cleanliness and dignity. The facility policy stated that if a resident refuses ADL assistance, staff should ensure the resident is safe, re-approach, and notify the nurse or manager if refusal continues.
Failure to Provide Routine Nail Care
Penalty
Summary
The facility failed to ensure routine personal hygiene, specifically nail care, was provided for a resident who was dependent on staff for ADLs. The resident’s MDS assessment identified severe cognitive impairment and dependence for personal hygiene, including nail care. The care plan stated that bath and nail care would be offered weekly by the nurse aide, but the EMR did not show weekly nail care provided with baths. A bath day sheet indicated the resident’s nails were cleaned and did not need clipping, yet during observation the resident was seen with long fingernails extending past the fingertips and curving downward with visible dark matter under the nails. On a later observation, the fingernails remained long and part of a fingernail was broken off on the right hand. An LPN confirmed the nails were long and should have been completed the prior week, and an RN/case manager stated the condition was unacceptable.
Failure to Provide Required Showering and Hygiene Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide required assistance with showering and personal hygiene for two residents who were dependent on staff for ADLs. One resident was observed with flaky skin and greasy hair, and the resident’s family member reported the resident was supposed to receive three showers or baths per week but was “lucky to get one.” The family maintained a calendar showing the resident received only four showers in the month of April. The resident’s admission record showed diagnoses including traumatic spondylolisthesis of the cervical spine, unspecified dementia, and cervical spinal stenosis. The quarterly MDS documented moderate cognitive impairment with a BIMS score of 10 and a need for substantial/maximal assistance with showering/bathing, with no documentation of care refusals. The resident’s care plan identified an ADL self-care performance deficit related to impaired balance, limited mobility, limited ROM, and neck pain, and contained no documentation of rejection of care or a pattern of negative responses. A second resident was observed with waist-length hair that appeared greasy at the crown and in need of washing. This resident stated she was supposed to receive three showers or baths per week but was “lucky” to get one, and reported staff told her they were short-staffed and that there was no bath team. Her admission record listed diagnoses including quadriplegia at C5–C7, bipolar disorder, and spinal stenosis. Her quarterly MDS documented that she was cognitively intact with a BIMS score of 15 and required partial/moderate assistance for showering/bathing, with no documentation of refusing care. Her care plan identified an ADL self-care performance deficit related to incomplete quadriplegia and did not document any concerns with rejection of care for ADLs, including showering. The DON and Administrator acknowledged that CNAs believed they were short-staffed without a bath team and were unaccustomed to providing baths and grooming when the bath team was unavailable, and that previously there had been no CNA room assignments, resulting in a lack of accountability for residents’ care. The facility’s ADL policy required that residents unable to perform ADLs independently receive services necessary to maintain grooming and personal hygiene and that refusals be documented in the clinical record.
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