An Avoidable Death and IJ

Good morning,

I am working on a new CEU course that dissects a choking related deficiency at a PA community in September of 2025.  The scenario gives me chills.

Some survey stories feel far away—things that happen at other buildings, to other teams.  

This isn’t one of them.

In Pennsylvania, a skilled nursing facility received Immediate Jeopardy under F684 (Quality of Care) and F689 (Supervision/Accident Hazards) after a resident died while choking during lunch. The resident had known risks. There was a policy. Staff had been trained. Therapies were involved. People responded.

And the resident still died.

CMS’s judgment was clear: care was delayed, and that delay contributed directly to the death.

This wasn’t about missing documentation. It wasn’t about lazy staff.
It was about a system that allowed people to hesitate.

What Actually Happened

The resident had aspiration risks and poor safety awareness. Speech Therapy had worked on pacing and small bites. OT had flagged cognitive safety concerns. The resident was on a mechanical soft diet.

During lunch, the resident started choking.

Staff saw it. They encouraged coughing. They stayed nearby.
At one point, the resident said, “I can’t.”

Instead of starting abdominal thrusts, staff kept coaching.
They tried suction. They moved the resident to his room. They transferred him into bed. More interventions followed.

But no one performed the Heimlich for about 10 minutes.

The resident didn’t survive.

CMS called it Immediate Jeopardy.

Why This Wasn’t About “One Person Messing Up”

The most uncomfortable part of this case is that staff were trying. This wasn’t someone on their phone or walking away. They were present. They cared.

That’s exactly why CMS cited the system.

Each isolated action—encouraging cough, trying suction, moving the resident—made sense. But collectively, they created fatal delay.

Once a resident can’t cough effectively, there’s no algorithm. No decision tree. No waiting for confirmation.
The intervention is immediate. Anything else is failure.

The Real Problem: Systems That Allow Delay

This facility had policies. They had annual trainings. What they didn’t have was a system that made the right action unavoidable.

There was no trigger point.
No clear line where hesitation had to stop.
No culture of certainty in a life-threatening moment.

Even the resident’s DNR status got pulled into the discussion. CMS addressed that directly: DNR does not apply to a conscious choking event. Bringing it into the decision-making process made the delay worse.

Training hours didn’t fail. Human reflex under pressure did. And that’s what CMS saw.

What NHAs Must Do This Week

If you're reading this and thinking, we have a choking policy, CMS has already shown that’s not enough.

Start here:

1. Talk to Staff—Unscripted

Ask your team:

• “What would you do if a resident told you they couldn’t cough?”

• "What do you do if a resident begins to choke?"

• “Would you wait for the nurse?”

• “Would you move them to their room?”

• “What if the resident is a DNR?”

Listen closely. Not to the words, but to the hesitations. The qualifiers. If you hear, “I’d check first” or “I’d ask the nurse,” your system is vulnerable.

2. Stop Auditing Paper. Watch Behavior.

A tray ticket won’t save a resident. Neither will a signed policy.

Go into the dining room. Observe what happens when someone eats too fast.
Do staff step in, or do they hope it resolves?

Hope is not a safety measure.

3. Retrain for Reflex

Training should remove decision-making—not create more of it.

Staff should not be choosing between suction, oxygen, movement, or reassessment. They should know one thing:
If the resident can’t cough, act. Immediately.

4. Own the Leadership Role

This wasn’t cited under obscure clinical regs. CMS held leadership responsible because the system failed.
As an NHA, that’s your call sign.

If your systems create delay, CMS won’t ask about intentions.
They’ll look at the outcome—and cite accordingly.

One Final Question

If someone starts choking in your dining room tomorrow, what happens in the first 10 seconds?

That moment—those 10 seconds—will determine whether your team is charting a resolved event or sitting across from surveyors weeks later reviewing an IJ tag.

Your policies won’t decide that.
Your good intentions won’t decide that.

Your systems will.

Test them now.

Whenever you're ready, I can help you in a few ways.

1. Get 1 FREE CEU - Read our partner Viventium's "2026 Healthcare Workforce Management Report" and receive 1 NAB approved CE credit. Read here. 
2. Use our free AI-powered Chatbot trained on all 900 pages of CMS Nursing Home Regulations, proprietary processes, and information from decades of skilled nursing leadership experience.  Click here.
3. Sign up for Assisto and keep track of the regulatory environment in your state.  Know what deficiencies surveyors cite in real-time and ensure you're not at risk for the same tag.  Sign up here.
4. Take our Salary Lens survey and gain access to the largest database of senior living and SNF leadership salaries in the industry.  Check it out here.

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Thanks for reading.  Have a wonderful day.

Kevin Goedeke, Publisher and Founder