Failure to Provide Required Supervision and Assistance During Meals Resulting in Resident Death
Penalty
Summary
A deficiency occurred when facility staff failed to protect a resident from neglect by not ensuring supervision and assistance during mealtimes, despite the resident's documented need for such support due to a history of cerebral infarction, dementia, and dysphagia. The resident was dependent on staff for feeding, as indicated in her care plan and medical records, which specified a mechanically altered diet and substantial/maximal assistance with eating. On the day of the incident, staff provided the resident with a covered food tray in her room and left her unsupervised, allowing her to consume her meal without the required assistance or monitoring. The resident was later found unresponsive by her roommate, who alerted a nurse. Facility staff initiated emergency interventions, including the Heimlich maneuver and CPR, and Emergency Medical Services were called. The resident was transported to the hospital, where she expired. Interviews and documentation revealed that staff did not check the resident's care plan prior to providing the meal, and there was a lack of communication and understanding among staff regarding the resident's need for supervision and assistance during meals. Additionally, the resident received the wrong food item on her tray, which was not consistent with her prescribed diet. Further investigation showed that the resident's family and speech language pathologist had previously communicated the need for supervision during meals due to the resident's tendency to eat too quickly and her inability to sense food on one side of her mouth. Despite these recommendations, staff routinely left the resident to feed herself and did not provide the necessary supervision or assistance. The facility's failure to follow the care plan and ensure proper supervision and dietary management directly contributed to the resident's choking incident and subsequent death.
Removal Plan
- Resident #2 discharged to the hospital and has not returned to the facility.
- The facility incorporated an additional notification on resident meal tickets through the meal tracker system to ensure facility staff are aware of the care and services needed by residents to include supervision and/or assistance during mealtimes in order to prevent further instances of neglect. The addition of this tray ticket notification indicator was complete.
- The DON and NHA received directed education by the Regional Nurse Consultant regarding abuse, neglect, and misappropriation as they relate to ensuring proper resident supervision and/or assistance during meals.
- Facility staff were provided education by the DON or designee regarding abuse, neglect, and misappropriation as they relate to ensuring proper resident supervision and/or assistance during meals. Contracted staff members were provided education regarding abuse, neglect, and misappropriation. Nursing and therapy staff were provided education by the DON or designee on ensuring proper resident supervision and/or assistance during meals. Education regarding the added notification on resident meal tickets was provided including the meaning of the indicator and what to do when they see it. This education was completed.
- An ad hoc Quality Assurance Meeting was held with the MD regarding removal plan activities. This meeting was held.