R0042

Failure to Supervise and Assist Cognitively Impaired Resident During Meals

Lake Woods Nursing & Rehabilitation CenterMuskegon, Michigan Survey Completed on 05-01-2025

Summary

An 84-year-old resident with severe cognitive impairment, vascular dementia with behavioral disturbance, affective mood disorder, insomnia, and dysphagia was observed during multiple lunch periods to be left unsupervised while eating. The resident, who was on a pureed diet with regular liquids and had a history of pocketing food, was provided with a single bowl of mechanically altered food and a plastic spoon, but no beverage was initially given. Staff were not present in the immediate area to monitor or assist the resident, despite her difficulties with self-feeding, including being unable to use the spoon effectively, resorting to eating with her fingers, and accumulating food on her hands, clothing, and the table. The resident was also observed chewing the same bite of food for extended periods, with staff only intervening after concerns were raised about food pocketing and lack of fluids.

Documentation indicated that the resident required only setup or clean-up assistance for eating, but direct observation showed significant challenges with self-feeding and a lack of timely staff intervention. The care plan and dietary orders were not effectively implemented, as the resident was not consistently provided with beverages and was not adequately monitored for safe eating practices, despite known risks such as food pocketing. Additionally, there was a discrepancy in care conference documentation, with staff reporting that a care conference with the resident's son had not occurred as documented, raising concerns about care coordination and communication.

Penalty

No penalty information released