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Based on interview and record review, the facility failed to provide care in a safe setting by not taking proper action for a patient choking on food during breakfast. This had the potential to affect any patient receiving meals from the facility (A144). The census was 289 patients.

Based on interview and record review, the facility failed to provide care in a safe setting by not taking proper action for a patient choking on food during breakfast. This had the potential to affect any patient receiving meals from the facility. The census was 289 patients.

Findings include:

Record review revealed Patient #2 was admitted to the facility on 11/08/16 with diagnoses including major neurocognitive disorder and schizophrenia.

A treatment plan dated 08/27/19 stated the patient was diagnosed with dementia, schizophrenia, complete loss of teeth and unspecified hearing loss.

A nursing note dated 08/28/19 at 12:31 P.M. documented while Patient #2 was eating, he began to choke. The nurse encouraged him to cough, he complied, and coughed up a big piece of bread. The physician was notified and gave an order to change Patient #2's diet to pureed. On 09/09/19 at 11:50 A.M., the physician changed the patient's diet to mechanical soft with no bread.

A progress note dated 09/15/19 documented while the patient was eating his breakfast he began to cough due to choking on eggs. As the nurse, Staff F, went to assist the patient, he began to walk to his room. The nurse asked Patient #2 if he was okay; he nodded yes, then started to fall to the floor. At 7:31 A.M., a "code blue" was called and Patient #2 was conscious. At 7:33 A.M., eight liters of oxygen were applied, the patient's pulse oxygenation level was 63 percent, and the patient lost control of his bladder. At 7:35 A.M. the patient was unresponsive, eight liters of oxygen continued to be given and the oxygen saturation was 30 percent. The note did not document the patient's respiration rate. At 7:40 A.M. the patient was unconscious with a pulse of 56 beats per minute and a blood pressure of 121/81. At 7:43 A.M. the patient was without a pulse, and the automatic external defibrillator was applied. No shock was delivered, and cardiopulmonary resuscitation (CPR) was initiated. At 7:45 A.M., emergency medical services (EMS) arrived. There was no documentation facility staff attempted the Heimlich maneuver, abdominal thrusts or suctioning to treat Patient #2's choking.

During interview on 10/08/19 at 9:15 A.M., Staff B stated Patient #2 choked. He said he responded to the "code blue" from another unit. He said he saw no staff attempt to remove an obstruction from the patient's airway. He said he saw EMS personnel suction eggs from the patient's mouth.

During interview on 10/08/19 at 10:39 A.M., Staff C stated she responded to the "code blue" and heard staff say Patient #2 began to choke and fell to the ground.

Review of the EMS run report dated 09/15/19 documented EMS personnel arrived on the scene at 7:41 A.M. Facility staff were providing CPR at that time. Facility staff stated Patient #2 had arrested five to eight minutes prior to their arrival. Facility staff told the EMS personnel that Patient #2 "appeared to have been choking on eggs." EMS personnel assumed CPR and the "patient had to be continuously suctioned for eggs in his mouth and throat." After 35 minutes of CPR, Patient #2 remained in asystole, with no heartbeat. CPR was stopped and Patient #2 was pronounced dead at 8:15 A.M. The cause of the cardiac arrest was documented as "respiratory/asphyxia".