Failure to Assess and Intervene for Change in Condition Related to Swallowing Difficulties
Penalty
Summary
A resident with Alzheimer's disease, severe cognitive impairment, and dysphagia was identified as being at risk for weight change and aspiration due to altered nutrition intake and swallowing difficulties. The care plan specified a pureed diet with thin liquids, close supervision during meals, and specific swallowing strategies. Despite these interventions, there were multiple documented incidents where the resident was found pocketing food, coughing during meals, and consuming food of inappropriate consistency, including an episode where whole kernels of corn were removed from his mouth. Staff interviews revealed that several CNAs observed ongoing issues with the resident's eating and swallowing, including frequent coughing and pocketing of food, and reported these concerns to nursing staff. There was a lack of timely and adequate assessment and intervention by nursing staff in response to the resident's change in condition. Progress notes and staff interviews indicated that nurses did not consistently assess the resident or notify the physician when changes were observed, such as when the resident was found with regular food in his mouth or when he exhibited increased coughing and difficulty swallowing. Staff also reported that their concerns were not always acknowledged or acted upon by nurses, and that the resident's condition deteriorated over a period of weeks, culminating in an acute episode of labored breathing, hypoxia, and fever. The resident was eventually hospitalized with aspiration pneumonia after being found with low oxygen saturation, fever, and lethargy. Medical records indicated that the resident had likely aspirated food of a different consistency, leading to pneumonia. The lack of prompt assessment and intervention following observed changes in the resident's eating and swallowing behavior contributed to the development of this serious condition.