According to the MDH report, during an interview, the resident resided in an assisted living facility. The resident’s diagnoses included dysphagia (difficulty swallowing) from a rare neurodegenerative disorder. The resident’s assessment identified under the activities of daily living section; the resident was independent with the physical function of eating. The assessment also identified choking and swallowing issues as nutritional risk factors. The assessment indicated interventions in place for the risk factors included encouraging him to eat in an upright position, to eat slowly, and to chew each bite thoroughly before attempting to swallow. Staff were to encourage him to use spoons for eating and discourage him from using straws. Additional interventions in place included observing the resident’s dining needs and report changes to the provider.

The resident’s death record identified cause of death due to lack of oxygen from food blocking the airway. An image of the resident’s meal tray included a plate with sliced sausages and sauerkraut. The plate also included bowls of fresh fruit and cottage cheese, each individually covered in plastic wrap, as well as plastic spoons and forks. During investigative interviews, staff members stated the resident did not receive assistance eating meals.

During an interview, the AP stated she had not been told the resident needed assistance with eating when she started. The resident asked for help cutting food as needed, but he ate by himself. The day of the incident, the AP took the resident’s lunch tray to his room. The resident sat in his wheelchair and told the AP thank you. Less than one hour later, the AP went back to collect the meal tray. The AP saw the resident leaning onto one side in his wheelchair. The AP thought the resident had been asleep and did not want him to fall, but he did not respond when
she called his name. The AP notified nursing who decided to call EMS.