Failure to Follow Care Plan for Meal Supervision of Resident with Dysphagia
Penalty
Summary
The facility failed to follow the care plan for a resident with a history of hemiplegia, hemiparesis following a stroke, dysphagia, and functional quadriplegia. The resident had severe cognitive impairment and required supervision or touching assistance with eating, as documented in the Minimum Data Set and care plan. The care plan specifically indicated the need for supervision during meals due to moderate oropharyngeal dysphagia, which impeded safe swallowing. Facility policy also required that residents receive meal assistance according to their individual needs. Multiple observations revealed that the resident was left unsupervised during meal times, both at breakfast and lunch, despite the care plan's requirements. Staff interviews indicated a lack of awareness or adherence to the supervision requirement, with one CNA stating he was unaware of the need for supervision and another leaving the resident unsupervised to answer a call light. The Speech Language Pathologist confirmed the necessity for supervision throughout the entire meal to ensure safe eating practices. The administrator acknowledged that clinical recommendations must be followed, and failure to do so could have led to adverse outcomes.