Failure to Provide One-to-One Feeding Assistance for Aspiration Precautions
Penalty
Summary
A deficiency occurred when a resident with a history of dysphagia and Alzheimer's disease, who had exhibited coughing or choking during meals and had a physician's order for one-to-one feeding assistance for aspiration precautions, was observed eating lunch independently in his room without staff supervision. The resident was seen consuming soup, juice, and a nutritional drink while intermittently coughing, and was outside the view of facility staff during the meal. The diet slip on the resident's tray did not include the physician's order for one-to-one feeding assistance. Interviews with the assigned CNA, LVN, Dietary Manager, and Director of Rehabilitation confirmed that the physician's order for one-to-one feeding assistance was active and that staff should have maintained visual supervision during meals. The CNA assigned to the resident was unaware of the order and allowed the resident to eat alone, contrary to the documented care plan and physician's instructions. The failure to communicate and implement the required supervision was verified through medical record review and staff interviews.