Example of a System Failure
Here is an example of a system failure:
- A surveyor observes that Individual #1 coughed four times while eating whole chicken he received during a meal. At another meal, the same individual coughed two times while eating whole bacon.
- The occupational therapist's (OT) assessment, dated three weeks prior to this observation, recommended a diet texture change to chopped food.
- The doctor's orders changed the diet to chopped food effective the same date as the OT's assessment.
- Interviews with direct care staff indicated they were not aware of a diet change.
- The diet card states, "regular texture."
- The QIDP said, "It's the house supervisor's job to change diet cards and train staff." She then said that she did not call an interdisciplinary team (IDT) meeting because, in her words, "choking is a nursing issue."