CHERAW, SC - A resident at Rehab Center of Cheraw died from choking on a hot dog after the facility failed to implement speech therapy recommendations for a mechanically altered diet, according to a state inspection report that found immediate jeopardy violations threatening resident health and safety.
Resident Served Wrong Food Despite Swallowing Disorder Diagnosis
The 62-year-old female resident, identified as R248 in the inspection report, had been diagnosed with dysphagia (difficulty swallowing), dementia, and aphasia when she was admitted to the facility. Despite multiple speech therapy evaluations recommending mechanical soft textures and nectar-thick liquids, she was served a regular dinner tray containing a chili dog with cheese on the day of her death.
According to the inspection findings, the resident's speech therapist had evaluated her multiple times between admission and discharge from therapy services. The final evaluation specifically recommended mechanical soft textures and nectar thick liquids due to documented swallowing difficulties. The facility's own policy clearly stated that hot dogs and sausages should be avoided unless ground or finely chopped for residents on mechanical soft diets.
Video surveillance footage reviewed by inspectors showed the resident eating alone in an empty day room at 5:24 PM. Seven minutes later, she was observed slumped over in her wheelchair. A staff member walked up to her, looked over, then left the room without providing assistance. Other staff members arrived one minute later and began CPR at 5:33 PM.
Critical Communication Breakdown Between Departments
The inspection revealed a systemic failure in communication between the speech therapy, nursing, and dietary departments. When interviewed, the Licensed Practical Nurse (LPN) on duty stated she "was aware that she had diagnoses of dysphagia, but she wasn't aware of any changes with her diet." The nurse believed the resident was always on a regular diet.
The speech therapist told inspectors he had completed diet communication slips with his recommendations and claimed he provided copies to both dietary and nursing departments. However, the resident's electronic medical records showed a diet order for "House, Nectar" with no mention of texture modifications, and her care plan contained no interventions related to her therapeutic diet requirements.
Dysphagia affects approximately 15% of elderly adults and significantly increases the risk of aspiration pneumonia and choking. When swallowing muscles weaken or coordination becomes impaired, food can enter the airway instead of the esophagus. Mechanical soft diets eliminate foods that require extensive chewing and exclude items like whole hot dogs that can obstruct airways. These dietary modifications are considered essential medical interventions for preventing life-threatening complications in dysphagic patients.
Emergency Response Reveals Extent of Obstruction
Emergency Medical Services documentation painted a grim picture of the incident's severity. The EMS report stated that responders "removed hotdog pieces from airway" after finding the resident in cardiac arrest. The emergency department physician who attempted resuscitation noted removing "a chunk of a hot dog from her left cheek" during intubation attempts.
The medical examiner's findings indicated the cause of cardiac arrest was "Respiratory/Asphyxia" due to airway obstruction. Despite 30 minutes of cardiac resuscitation and multiple rounds of epinephrine, medical personnel were unable to revive the resident.
Standard protocols for residents with dysphagia require not only appropriate food textures but also supervised eating environments. The resident's assessment indicated she required "supervision or touching assistance when eating," yet she was found eating alone in an empty day room. This represents a fundamental breach of basic safety protocols for vulnerable residents with known swallowing disorders.
Additional Issues Identified
The inspection uncovered several other concerning deficiencies in the facility's dysphagia management program. The facility's rehabilitation services policy required speech language pathologists to screen all residents at least every six months to assess feeding tube needs and eating skills. However, documentation gaps suggested inconsistent implementation of these screenings.
Staff training deficiencies were also apparent, with a certified nursing assistant stating she wasn't familiar with any residents who had difficulty swallowing, despite caring for R248 who had documented dysphagia. The dietary department's meal tracking system failed to reflect the speech therapy recommendations, continuing to provide regular texture meals even after therapeutic diet orders should have been implemented.
The facility's immediate jeopardy removal plan acknowledged that the "new diet recommendation not communicated effectively by speech therapist to dietary or nursing departments" and announced the suspension of the speech language pathologist pending investigation. The facility committed to auditing all current residents' diets against speech therapy recommendations and implementing a new system requiring diet communication slips to be reviewed in daily clinical meetings.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Chesterfield Convalescent Center from 2025-05-06 including all violations, facility responses, and corrective action plans.
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