Failure to Supervise Cognitively Impaired Resident During Meals Leads to Choking Risk
Penalty
Summary
A deficiency occurred when staff failed to provide a safe environment free from accident hazards for a resident with severe cognitive impairment and a history of choking. The resident, who was prescribed a mechanically altered diet and required staff assistance and supervision during meals, was observed eating independently without supervision on multiple occasions. During these times, the resident was able to take large bites, eat inappropriate foods, and take food from other residents' plates, all without staff intervention. The resident's care plan specifically directed staff to assist with controlling the rate of eating, monitor bite sizes, and prevent the resident from stuffing food into his mouth. Despite these interventions being documented, staff did not consistently implement them. Observations showed that the resident was served food items not consistent with the prescribed diet and was not monitored to prevent access to other residents' food. Staff were also observed delivering food and then leaving the resident unsupervised, failing to ensure safe eating practices. Interviews with staff confirmed that the resident had a known tendency to grab food from others and put inappropriate items in his mouth, and that supervision was required during meals. However, staff were not always aware of previous choking incidents, and meal observations confirmed that the required supervision and care-planned interventions were not provided. This lack of supervision and failure to follow the care plan placed the resident at continued risk for further choking incidents.
Removal Plan
- Serve R77 food per the physician's ordered diet of a mechanical soft diet.
- The Certified Nurse Aide (CNA) and/or nurse will provide R77 with supervision during intake to ensure he is eating safely.
- Place R77 on safety checks due to his behavior of taking other residents' food that is not within his prescribed diet texture.
- Address any additional safety concerns or behaviors, document in the behavior log, and update the care plan with appropriate interventions.
- Review and update the care plan and interventions with every change of condition.