Failure to Ensure Safe Positioning During Meals
Penalty
Summary
A deficiency was identified when a resident with a history of hemiplegia, cerebral infarction, and dysphagia was repeatedly observed eating meals while lying in bed with the head of the bed elevated less than 15 degrees. The resident's care plan noted risks related to altered nutritional status and swallowing difficulties. Despite this, multiple observations showed the resident eating in a reclined position, and the resident reported some difficulty eating in that position. Staff interviews revealed inconsistent practices, with some staff stating they positioned the resident upright for meals, while others acknowledged the resident sometimes refused to be repositioned. The Director of Nursing confirmed that residents should be upright during meals, but stated the resident was resistant to having the bed elevated. The facility did not have a policy on positioning residents while eating. The lack of consistent implementation of safe positioning practices and absence of a formal policy contributed to the failure to ensure the resident was positioned safely during meals, as required to prevent accidents such as choking.