Failure to Provide Required Supervision and Assistance During Meals Resulting in Resident Death
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral infarction, dementia, and dysphagia was not provided the required supervision and assistance during mealtime, as outlined in her care plan and supported by speech therapy recommendations. The resident was dependent on staff for feeding and required a mechanically altered diet, yet staff failed to check her care plan before delivering her meal tray and left her unsupervised in her room. The resident consumed her meal without assistance, despite documented needs for close supervision due to her cognitive impairment and swallowing difficulties. On the day of the incident, the resident was found unresponsive by a nurse after her roommate alerted staff. The nurse and other staff initiated emergency procedures, including CPR and the Heimlich maneuver, due to suspected choking. EMS arrived and continued resuscitation efforts, noting the presence of emesis and food in the resident's airway. The resident was transported to the hospital, where she later expired. Documentation and interviews confirmed that the resident had not been consistently assisted or supervised during meals, and her care plan interventions were not followed by the staff responsible for her care. Interviews with facility staff, the resident's family, and the speech language pathologist revealed that the resident's need for supervision and assistance during meals was known but not consistently communicated or implemented. Staff members involved in meal delivery and care did not review the care plan or receive adequate handoff information regarding the resident's needs. The failure to provide supervision and assistance during meals, as required by the resident's care plan and clinical recommendations, directly led 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 ensuring proper resident supervision and/or assistance during meals is occurring.
- A total of 104 out of 104 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 100% completed.
- An ad hoc Quality Assurance Meeting was held with the MD regarding removal plan activities.