Failure to Ensure Proper Positioning During Meals
Penalty
Summary
The facility failed to ensure that a resident with severely impaired cognition and a history of [REDACTED] received appropriate positioning during meals, as per professional standards of practice. The resident, who was dependent on staff for all activities of daily living, including eating, was observed multiple times sliding down in their chair while being assisted with feeding. Despite the resident's diet being downgraded to pureed consistency with honey thickened liquids due to increased coughing and gagging, there were no interventions documented in the care plan regarding proper positioning during meals. Interviews with staff revealed that the resident had not been evaluated by occupational or physical therapy for chair positioning during feeding, and no devices were initially used to prevent the resident from sliding down. The Registered Nurse Unit Manager acknowledged the difficulty in feeding the resident and the lack of an upright position during meals. An Occupational Therapist confirmed that a screen for positioning had not been requested, although devices were available to assist with proper positioning. It was only after a family request and subsequent evaluation that a device was added to help prevent the resident from sliding down in the chair.
Plan Of Correction
Plan of Correction: Approved March 21, 2025 F684 Quality of Care I. Immediate Corrections - The Director of Rehab conducted a complete and thorough investigation into the resident’s plan of care regarding their positioning in the wheelchair during mealtimes. The Occupational Therapist assessed the resident during lunch on 2/27/2025 and added a positioning wedge under the front end of the cushion to help prevent them from sliding down in the wheelchair. - The CNA was educated regarding the positioning wedge and how to ensure the resident was properly positioned in the wheelchair. The nurse and RN supervisor were also provided with an in-service on the use of the device. II. Plan of Correction to identify other areas potentially affected - The Director of Rehab reviewed all residents in the facility positioning during mealtimes to ensure all were safely and appropriately positioned and all positioning devices (have orders and) were included in the comprehensive care plans. - In-service was also provided to all CNAs assigned to each resident. Respectfully, no other residents were identified to have been affected at this time. III. Systemic Changes - The policy for positioning was reviewed and found to be compliant with the regulations. The licensed nurses, CNAs, and licensed therapists were educated on the updated policy and the need to ensure all devices are in place in the care plans to reflect the condition of the residents. A copy of the lesson plan and attendance sheets will be kept on file for validation. IV. Quality Assurance Monitoring - The Director of Rehab/designee will perform monthly audits for the positioning of residents during mealtimes on all units x 3 months, then quarterly thereafter to ensure residents are properly positioned, any positioning devices are in place, and care plans are accurate and reflect the services required by the residents. Any outstanding issues will be corrected on site by the auditor. - All audit findings will be reported to the Administrator and QA committee. Responsible Party: Director of Rehab/Designee