Failure to Provide Required Meal Supervision for Resident with Dysphagia
Penalty
Summary
Staff failed to follow a physician's order requiring one-on-one supervision during meals for a resident with a history of hemiplegia, hemiparesis, dysphagia, and functional quadriplegia. The resident, who had severe cognitive impairment and required supervision or assistance with eating, was observed consuming meals alone in their room on multiple occasions. Despite clear documentation in the resident's care plan, Kardex, and tray tickets specifying the need for supervision, staff did not remain with the resident during meal times. Interviews with CNAs revealed a lack of awareness or adherence to the supervision requirement, with one CNA stating they were 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. Facility leadership acknowledged that clinical recommendations and orders must be followed, and failure to do so could have led to adverse outcomes.