Resident on NPO Diet Fed Pizza by Another Resident
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for a resident who was on a Nothing by Mouth (NPO) diet due to a high risk for aspiration pneumonia. The resident, who had a history of cerebral palsy, Parkinson's disease, and developmental disabilities, was nonverbal and communicated using a communication board. Despite having a gastrostomy tube for feeding and being assessed as high risk for aspiration, the resident was given a slice of pizza by another resident while in a common area. This incident occurred without staff awareness, leading to the resident coughing and requiring medical assessment and monitoring. The resident's care plan and physician orders clearly indicated that the resident was to receive nutrition exclusively through tube feeding, with no oral intake. However, the resident was allowed to be in a common area where other residents had access to food, which led to the incident. Staff interviews revealed that the resident enjoyed being in the common area, but there was a lack of adequate supervision to prevent the resident from accessing food. The incident was documented, and a chest X-ray was ordered to check for aspiration, which returned negative. The deficiency highlights a failure in monitoring and supervision, which resulted in the resident accessing food contrary to their dietary restrictions.
Plan Of Correction
Plan of Correction: Approved March 7, 2025 What corrective actions were taken for the affected resident: 1. Resident #1 suffered no ill effect from receiving pizza from another resident. Resident #1 was assessed by the Nurse Practitioner and chest radiograph was negative for aspiration pneumonia. Care plan was reviewed and revised. How will you identify others at risk to be affected by the alleged deficient practice: 1. A review on 2/12/2025 of current diet orders reveals no other residents have order for Nothing By Mouth. 2. Diet orders will be reviewed on all new admissions to identify residents with Nothing By Mouth status placing them at risk to be affected. Those at risk will be care planned appropriately. What measures will be put in place or what systemic changes you will make to ensure that the alleged deficient practice does not recur: 1. All staff were educated on “Special Considerations for the Resident who is Nothing By Mouth.” 2. The facility will continue to educate all staff on “Special Considerations for the Resident who is Nothing By Mouth” on hire and annually. How the corrective action(s) will be monitored to ensure the deficient practice will not recur: 1. Nursing staff will conduct weekly audits of activities and/or dining to ensure residents with NPO orders are not present while food is being served. Audits will be conducted on various shifts weekly for four (4) weeks then monthly for two (2) months. Audit results will be forwarded to the Quality Assurance Process Improvement Committee for review and further recommendation. Responsibility: Director of Nursing or Designee