Inadequate Supervision of Feeding for Resident with Dysphagia
Summary
The facility failed to ensure that residents with difficulty swallowing were assisted with meals by qualified individuals. During an observation, an activity aide was seen feeding a resident who was supposed to be on a pureed diet but was given a mechanical soft diet at the family's request. The resident, who had a history of stroke, dysphagia, and left-sided hemiplegia, was at risk of aspiration and required staff assistance during meals. Despite these needs, the facility allowed unlicensed staff to feed the resident, contrary to the recommendations by speech therapy and the facility's own policies. The resident's care plan and shared risk agreement indicated the need for a mechanically soft diet with honey thick liquids, acknowledging the risks of aspiration and pneumonia. However, the facility's director of nursing confirmed that unlicensed staff were permitted to feed residents, including those with swallowing concerns. The medical director was unaware that staff had not reassessed who could feed the resident, highlighting a lack of communication and oversight. The facility's training program for feeding assistants did not align with federal requirements, which state that feeding assistants should only assist residents without complicated feeding problems, such as difficulty swallowing.
Penalty
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Staff failed to follow facility policy for assisting with in-room meals for three cognitively impaired residents who required varying levels of help with eating. One resident with metabolic encephalopathy, dementia, and total dependence for eating was found lying flat in bed with food in the mouth and on the linens while the meal tray remained mostly untouched and covered; the assigned CNA had been redirected to the dining room to assist two other residents needing feeding help and did not promptly return. For all three residents, care plans required documentation of PO intake at every meal, but intake records for the cited day showed either no intake data or "resident not available," and the CNA did not report decreased intake to an LVN as expected. Interviews revealed that usual restorative nursing assistant coverage in the dining room was absent that day, CNAs were managing multiple feeder residents, and charge nurse supervision did not ensure that feeding assistance and intake documentation were completed according to policy.
The facility did not ensure that residents receiving paid feeding assistance were properly assessed for program appropriateness, nor did it verify that staff providing this assistance had completed required training. A resident with swallowing difficulties received feeding assistance without documented assessment, and another was assisted by a staff member unable to provide proof of training. Facility policy required both assessments and verified training, but these were not documented or completed.
A resident with severe cognitive impairment and special dietary needs was fed by a Unit Assistant who had not completed the required State-approved feeding assistant training. Facility staff and leadership confirmed that Unit Assistants received only in-house training and were unaware of the need for State-approved certification, resulting in the resident being assisted by unqualified personnel.
A resident with dysphagia and partial paralysis had a physician order for 1:1 supervision and assistance during meals, including cues to slow eating and pre-cut food. Staff were observed leaving the resident unattended during meals, and there was no documentation of required supervision for the past month. Facility policies required following physician orders and providing meal assistance based on individual needs, but these were not followed.
A resident with severe cognitive impairment and a pureed diet was assisted with meals by a PNA without documented assessment or care plan inclusion, and staff were unaware of requirements for evaluating or documenting PNA use. Facility staff demonstrated confusion about supervision and assignment of PNAs, and the process outlined in facility policy was not followed.
A social worker without state-approved feeding assistant training assisted a resident with moderate cognitive impairment and neurological conditions during a meal. The staff member was observed feeding the resident, despite not having completed the required training, and the facility lacked a policy or training for non-nursing staff on assisted feeding.
Failure to Provide and Document Required Feeding Assistance and Intake Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to follow its policy and procedures for assisting residents with in-room meals, including providing needed feeding assistance, documenting meal intake, and ensuring appropriate reporting of decreased intake. For three cognitively impaired residents with significant functional limitations, staff did not consistently assist with feeding as required by their assessments and care plans, nor did they document meal intake percentages as directed. The facility also failed to ensure that a CNA notified licensed nursing staff when a resident had decreased meal intake. Resident 1 was admitted with multiple diagnoses including metabolic encephalopathy, dementia, diabetes, muscle weakness, anemia, hypertension, a pressure ulcer, and GERD. The MDS showed cognition was not intact and that Resident 1 required maximal assistance with eating and was dependent for toileting, showering, and transfers. A nutrition assessment indicated total assistance was required for eating, and the care plan identified decreased self-feeding abilities related to metabolic encephalopathy and dementia, as well as nutritional risk with an intervention to document PO intake at every meal. On observation, Resident 1 was found lying flat in bed with eyes closed, chewing with orange material in the mouth and on the lips, and a half-eaten piece of potato on the sheet next to the face. The meal tray was on the bedside table with the cover still on; the plate contained mostly uneaten food and an unopened juice. CNA 1, who was assigned to Resident 1 and stated this was the first time caring for this resident, did not begin feeding until later, after being redirected to assist other residents in the dining room, and there was no documentation of meal intake for Resident 1 on the cited date, nor evidence that decreased intake was reported to an LVN. Resident 3 had diagnoses including right-sided hemiplegia/hemiparesis, encephalopathy, UTI, COPD, diabetes, muscle weakness, aphasia, dysphagia, hyperlipidemia, anxiety disorder, and hypothyroidism, with an MDS indicating cognition was not intact and that supervision or touch assistance was required with eating. The care plan identified nutritional risk with an intervention to document PO intake at every meal, and a physician order specified a fortified regular pureed diet, level 4 texture, thin consistency, and that the resident was a feeder. Meal intake documentation for the referenced date showed “resident not available.” Resident 4, with hemiplegia/hemiparesis after cerebral infarction, asthma, epilepsy, protein-calorie malnutrition, muscle weakness, dysphagia, UTI, aphasia, hyperlipidemia, and hypertension, also had impaired cognition and required moderate assistance with eating. The care plan for Resident 4 included documenting PO intake at every meal, yet the same date’s intake record also indicated “resident not available.” Interviews revealed that CNA 1 was simultaneously assigned to Residents 1, 3, and 4 and was pulled to the dining room to assist Residents 3 and 4 when no restorative nursing assistants were present, leaving Resident 1 without timely feeding assistance and contributing to the lack of proper intake documentation and reporting for all three residents. Staff interviews further clarified the breakdown in supervision and adherence to policy. CNA 1 reported starting to feed Resident 1 but being told to go to the dining room to assist Residents 3 and 4, who also needed feeding assistance, and only returning later to finish feeding Resident 1. LVN 1 confirmed that Resident 1 required assistance with feeding and stated that CNA 1 did not request help or report any decreased intake, despite the expectation that CNAs report intake of less than 50% and complete a “stop and watch” form. The RNA stated that there are usually three RNAs assigned to the dining area to pass trays and feed residents, but on the day in question one RNA had called off and the remaining RNA was sent out with another resident to an appointment and did not return until mid-afternoon, leaving the dining room without RNA coverage. LVN 2 observed there were no RNAs in the dining room and that CNAs were taking residents back to their rooms. The ADON later explained that one RNA had called off and the other was at an appointment, and that charge nurses were expected to monitor whether residents needing feeding assistance were being helped and to supervise CNAs, including adjusting assignments when a CNA had multiple residents requiring feeding assistance. Despite these expectations and the written policy on assisting residents with in-room meals and documenting intake, the facility did not ensure that Residents 1, 3, and 4 were assisted with feeding as care planned, that their meal intake percentages were documented, or that decreased intake for Resident 1 was reported to licensed nursing staff. The facility’s written policy on assisting residents with in-room meals required staff to review the resident’s care plan, ensure appropriate positioning and preparation for meals, assist residents as necessary while encouraging self-feeding, and document the date and time of the procedure, the staff involved, the percentage of the meal consumed, the resident’s participation, and any special requests. Observations and record reviews showed that these steps were not followed for the three residents on the date in question. Resident 1 was not positioned upright as specified in the policy when first observed with food in the mouth and on the bed, and the tray remained covered and largely uneaten until CNA 1 returned. For Residents 1, 3, and 4, the required documentation of meal intake percentages was either missing or recorded as “resident not available,” and there was no evidence that CNA 1 notified an LVN or RN of Resident 1’s decreased intake, contrary to facility expectations and the care plan interventions. These combined observations, interviews, and record reviews demonstrate that the facility did not implement its own policy and procedures for assisting residents with in-room meals and did not ensure that residents were assessed and supported appropriately for feeding assistance, that meal intake was documented as care planned, or that decreased intake was reported to licensed staff for further evaluation.
Failure to Assess Residents and Verify Staff Training in Paid Feeding Assistance Program
Penalty
Summary
The facility failed to ensure that residents receiving paid feeding assistance were properly assessed for appropriateness and that staff providing this assistance were adequately trained. One resident required one-person total assistance with eating and was observed being assisted by a recreation therapist, who claimed to have received paid feeding assistant training. However, the staff member was unable to provide a valid training certificate, and the facility could not locate documentation confirming completion of the required training. Another resident, who had documented swallowing difficulties and required thickened liquids, was also receiving paid feeding assistance. Review of the resident's records showed no documentation of an assessment to determine if they were appropriate for the paid feeding assistance program, despite facility policy requiring such an assessment for residents with complicated feeding problems, including swallowing difficulties. Interviews with facility staff revealed a lack of awareness regarding responsibility for completing these assessments, and the Director of Nursing confirmed that the resident did not meet the criteria for the program and that no assessment documentation existed. Facility policy stated that only residents without complicated feeding problems should be considered for the paid feeding assistant program and that only appropriately trained staff should provide this assistance. The lack of assessment and training documentation for both residents and staff led to the deficiency, as residents with special dietary needs and risks were assisted by staff whose qualifications could not be verified.
Unqualified Staff Fed Resident Without State-Approved Training
Penalty
Summary
A deficiency was identified when a resident with Alzheimer's disease, dementia, and abnormal weight loss, who was dependent on staff for all activities of daily living including eating, was fed by a Unit Assistant who had not completed a State-approved feeding assistant training course. The resident required a mechanically altered diet with aspiration precautions, and the care plan specified that staff should feed and assist the resident to complete meals. During observation, the Unit Assistant was seen feeding the resident puree food, and both the Unit Assistant and facility leadership confirmed that the assistant had only received in-house training and was unaware of the requirement for State-approved training. Interviews with the Director of Human Resources and the Director of Nursing revealed that Unit Assistants routinely feed residents after receiving facility-based training, but none had completed the required State-approved eight-hour course. Documentation supporting completion of State-approved training for feeding assistants was not available, and facility leadership was not aware of the regulatory requirement for such training. This resulted in the resident being fed by unqualified staff, contrary to regulatory requirements.
Failure to Provide Required Supervision and Assistance During Meals
Penalty
Summary
A resident with diagnoses including dysphagia and partial paralysis to the left side was admitted to the facility and had a physician order for 1:1 supervision during meals, cues to slow eating, and pre-cut food into bite-sized pieces. Observations revealed that the resident was left unattended during meal times, with staff delivering meal trays, positioning the resident, and then leaving. On two separate occasions, the resident was found alone with her meal tray, without the required supervision or assistance. A review of the resident's electronic record showed no documentation of 1:1 supervision for meals over the past 30 days, despite the physician's order. When requested, the facility was unable to provide a policy and procedure defining levels of meal assistance. The facility's existing policies indicated that residents should receive meal assistance according to their individual needs and that physician orders should be followed as prescribed. The nurse practitioner confirmed that staff are expected to follow orders for resident safety.
Failure to Assess and Care Plan for Feeding Assistant Use
Penalty
Summary
The facility failed to ensure that residents were properly assessed for appropriateness before being assigned to the Paid Nutritional Assistant (PNA) program, and did not document or reflect the use of PNAs in the residents' care plans. For one resident with severely impaired decision-making, memory problems, and a history of stroke and Alzheimer's Disease, there was no documented assessment to determine if a PNA could safely assist with feeding. The care plan did not specify whether a PNA could provide meal assistance, and staff interviews revealed a lack of awareness regarding the need for such assessments or care plan documentation. Observations confirmed that a PNA assisted the resident with meals, but staff, including the DON and RNs, were unaware of the requirement for assessment or care plan inclusion for PNA use. Further, staff interviews indicated confusion about supervision and assignment of PNAs, with some staff unsure who was responsible for supervising PNAs or how residents were selected for PNA assistance. The facility's policy required that a nurse assign PNAs only to residents without complicated feeding problems, based on assessment and care plan, but this process was not followed. Documentation and staff knowledge gaps led to the use of PNAs without proper assessment, care planning, or clear supervision, as required by facility policy and regulatory standards.
Untrained Staff Assisted with Resident Feeding
Penalty
Summary
A deficiency occurred when a social worker, who had not completed a state-approved feeding assistant training course, assisted a resident with eating. The resident, an elderly female with Parkinson's Disease, generalized anxiety disorder, and essential tremor, was admitted with moderate cognitive impairment and required supervision with eating. During observation, the social worker was seen feeding the resident a tuna sandwich by bringing the food to her mouth, while the resident was unable to feed herself independently due to her condition. Interviews with the social worker, administrator, and DON revealed that the social worker was not trained in feeding assistance and that the facility did not provide specific training on feeding residents to non-nursing staff. The social worker's training record confirmed the absence of a state-approved feeding training course. The administrator and DON stated that only CNAs and nurses received feeding training as part of their competencies, and there was no policy on assisted feeding for other staff.
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