Failure to Provide 1:1 Feeding Assistance and Proper Positioning During Meals
Penalty
Summary
The facility failed to provide one-to-one feeding assistance and proper positioning during meals for a resident with severe cognitive impairment and multiple medical diagnoses, including dementia, flaccid hemiplegia, and dysphagia. The resident's care plan specified a mechanically altered, pureed diet, nectar consistency liquids, and required the head of bed to be elevated during meals, as well as one-to-one feeding assistance due to impaired self-feeding ability. Despite these documented interventions, the resident was observed in bed at a 45-degree angle, attempting to eat a pureed diet without staff assistance. The resident's left hand was flaccid and not being used, and no staff were present to assist or monitor the resident during the meal. Staff interviews confirmed that the resident should have been positioned upright and provided with one-to-one feeding assistance as per the care plan. The LPN and Interim DON both acknowledged that eating at a 45-degree angle could lead to aspiration, and the Restorative Director stated that the resident was care planned for one-to-one feeding assistance and should be upright while eating. Facility policy also required residents to be positioned at 60 to 90 degrees during meals. The failure to follow the care plan and facility policy resulted in the resident not receiving the required assistance and positioning during mealtime.