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Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure Patient #1 received care in a safe setting by not adhering to Physician's orders for a therapeutic diet for one (1) of eleven (11) sampled patients who were ordered specialized diets.

The findings include:

Policy review of the facility's "Patient Meals and Unit Food Policy" (Policy # PTC-0021), undated revealed "Choking protocol shall be followed for all patients identified as a choking risk."

Review of Patient #1's medical record revealed the facility admitted the patient on 03/09/16 with a primary psychiatric diagnosis of Chronic Schizophrenia and a secondary diagnosis of Dysphagia. Review of the Patient #1's Personal Recovery Plan (PRP), revealed on 07/25/16 the patient was identified as a choking risk related to difficulty swallowing or chewing food. Resident was receiving a physician ordered Mechanical Soft Diet until 08/24/16, when the order was changed to a Pureed Diet, as indicated by the PRP.

Review of the facility "Incident Report Form", revealed on 08/21/16 at 6:55 PM, staff started to change Patient #1's ostomy, and he/she began to cough and his/her face turned red. Further review revealed Patient #1 stopped coughing and was unable to inhale and Registered Nurse (RN) #1 performed the Heimlich Maneuver and a peanut expelled from the patient's mouth. Per the Incident Report, Mental Health Associate (MHA) #1 admitted to giving the patient a peanut "M & M" candy.


Interview on 08/25/16 at 6:38 PM, with MHA #1, revealed on 08/21/16 she had a small bag of Peanut "M&M's" candies in her hand when Patient #1 asked her for a piece of candy. The MHA stated she was "not thinking", and was just trying to be friendly and gave Patient #1 one (1) peanut M&M candy. MHA #1 stated after receiving the M&M candy, the patient went to his/her room. MHA #1 revealed later during the same shift, she was informed by facility nursing staff Patient #1 had choked on the the M&M candy during a colostomy bag change and required the Heimlich Maneuver to be performed on him by Registered Nurse (RN) #1. During the interview, MHA #1 revealed she was aware Patient #1 had been identified as a choking hazard prior to giving him/her an M&M. The MHA further revealed although she knew the patient was a choking risk, it never occurred to her she was giving the patient a peanut. The MHA stated in her mind, she was just giving the patient a piece of candy.

Interview on 08/25/16 at 5:10 PM, with RN #1, confirmed she had to administer the Heimlich Maneuver to the patient on 08/21/16 after he/she choked on the peanut from a Peanut M&M candy.

Interview on 08/25/16 at 5:22 PM, with the Unit Manager where Patient #1 was assigned, revealed if a patient was a choking risk their names were placed on the giant communication board in the report room. The Unit Manager further revealed the facility used blue wrist bands to identify patients who were choking risks.

Observations made on 08/25/16 at 5:30 PM confirmed Patient #1 was identified as a choking risk on the communication board in the facility's report room and he/she was wearing a blue wrist band, indicating he/she was at risk for chocking.

Interview on 08/26/16 at 11:15 AM, with the facility's Director of Nursing, revealed it was his expectation the facility staff follow Physician's orders and the PRP related to a patient's dietary restrictions.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure Patient #1's Plan of Care/Personal Recovery Plan was followed by not adhering to a Physician ordered therapeutic diet for one (1) of eleven (11) patients who were ordered specialized diets.

The findings include:

Policy review of the facility's "Personal Recovery Plan (PRP)" (Policy # ADM0016), undated, revealed a PRP development process began at admission and had measurable recovery goals within the capabilities of the individual.

Review of Patient #1's medical record revealed the facility admitted the patient on 03/09/16 with a primary psychiatric diagnosis of Chronic Schizophrenia and a secondary diagnosis of Dysphagia. Review of the patient's Personal Recovery Plan (PRP), revealed on 07/25/16 the patient was identified as being a choking risk related to difficulty swallowing or chewing food. The goal stated the patient would have no choking episodes while eating or drinking. The interventions included assessing the patient's swallowing ability.

Review of the facility "Incident Report Form", revealed on 08/21/16 at 6:55 PM, when staff started to change Patient #1's ostomy, he/she began to cough and his/her face turned red. Further review revealed Patient #1 stopped coughing and was unable to inhale and Registered Nurse (RN) #1 performed the Heimlich Maneuver and a peanut was expelled from the patient's mouth. Per the Incident Report, Mental Health Associate (MHA) #1 admitted to giving Patient #1 a peanut "M & M" candy.

Interview on 08/25/16 at 6:38 PM, with MHA #1, revealed she was eating a small bag of Peanut M&M's candies on 08/21/16, when Patient #1 asked her for a piece of candy. The MHA revealed she was "not thinking" and was just trying to be friendly to the patient and gave the patient one (1) M&M candy. She stated, after Patient #1 received the candy, he/she went to his/her room. Further interview with MHA #1, revealed later during the same shift, she was informed by facility nursing staff Patient #1 had choked on the the M&M candy during a colostomy bag change and the Heimlich Maneuver had to be performed by Registered Nurse (RN) #1. Per interview with MHA #1, she knew Patient #1 was a choking risk because he/she had been identified on the giant dry erase board located in the unit's report room as a choking risk. She stated, it never occurred to her she was giving him/her a peanut, because in her mind, she was just giving the patient a piece of candy.

Interview on 08/25/16 at 5:10 PM, with RN # 1, verified she had to administer the Heimlich Maneuver to Patient #1 on 08/21/16 after he/she choked on the peanut from a Peanut M&M candy.

Interview on 08/25/16 at 5:22 PM, with the Unit Manager where Patient #1 was assigned, revealed facility staff had a couple of ways of knowing which patients were at risk for choking. Per interview, if a patient was a "choking risk" their names were placed on the giant communication board in the report room, and also the patients wore blue wrist bands to designate they were at risk for choking. Further interview, revealed each staff member received report in the report room, prior to the beginning of their shift and the board was reviewed at that time. The Unit Manager further revealed, during change of shift report, staff was told by the off-going RN which patient's were on choking precautions. Per interview, "if it is not stated during oral report, staff are expected to look at the giant dry erase board and see which patients are on restrictions."

Observations made on 08/25/16 at 5:30 PM, confirmed Patient #1 was identified as a choking risk on the communication board in the facility's report room and he/she was wearing a blue wrist band, indicating he/she was at risk for choking.

Interview on 08/26/16 at 11:15 AM, with the facility's Director of Nursing, revealed it was his expectation facility staff would follow a patient's PRP and also follow Physician's orders in regards to a patient's dietary restrictions.