The Manor Of Farmington Hills

done prior to nurses entering the dining room.

The DON was also asked as to their statement in the IA that said R701 had an episode of dysphasia while consuming her meal that resulted in death.

The DON noted that perhaps they did not complete a well written summary.

The DON was asked if they were aware that R701 was exhibiting signs of trying to eat non-food items and confused as noted in the IDG Hospice document.

The DON noted that they were not aware of that document.

The Administrator noted that the IDG forms were put into the resident's electronic record by non-medical staff and as such may not have been read.The facility policy titled, Incidents and Accidents for Residents was reviewed and documented, in part: Policy: Incidents or Accidents involving a resident will be documented and reported so as to meet regulatory requirements.A Facility Incident and Accident Report must be completed by a licensed nurse.Potential witnesses shall be interviewed and the occurrence of such interviews will be documented on the Incident and Accident Investigation Form.A review of a study from the National Library of Medicine titled, Age Related Changes to Eating and Swallowing Impact Frailty: Aspiration, Choking Risk was reviewed and noted, in part, the following: .The need for supervision is an environmental risk factor for choking.sedating medication may increase choking risks that could be mitigated with supervision or assistance at meal times. In pathologic aging, cognitive impairment such as that which accompanies dementia, increase choking risk with behaviors such as eating too fast, not chewing very much, over-filling the mouth or swallowing large mouthfuls.

Inadequate mealtime supervision of individuals at risk of choking has had fatal consequences.

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