An elderly woman was admitted from the hospital to a nursing home. Her admitting diagnosis included dementia, difficulty swallowing, the need for supervision while eating, and the need for a ground or pureed diet. The nursing home staff testified the facility was understaffed, that they did not have time to supervise the residents while eating, and that they had complained to management about the problems, and that management did not provide more help. The lady was not given a ground or pureed diet and she was left unattended while eating. As a result, she choked on her food the first three meals she received. On the evening of day one, a family member found her gagging on a hotdog that was not ground or pureed. On the second day at lunchtime a nurse found her unattended in her room choking on food that was not ground or pureed. The nurse actually saved the women’s life by performing the Heimlich maneuver. That evening she was found dead in her room. An autopsy revealed she choked to death on a large piece of meat that was not pureed.