Failure to Provide Required Supervision During Meals for Resident with Aspiration Risk
Penalty
Summary
Facility staff failed to implement a person-centered care plan for a resident with significant aspiration risk, as evidenced by multiple observations of the resident eating meals unsupervised in their room. The resident, who had a history of dysphagia following a stroke and prior aspiration pneumonia, was on a physician-ordered puree diet with honey thick liquids and required continual supervision during oral intake, as documented in the care plan and physician's orders. Despite these clear directives, the resident was observed eating alone behind a closed privacy curtain, out of staff view, on more than one occasion. Interviews with staff confirmed that the resident should not have been left unattended with food due to the risk of aspiration. The nurse responsible for the resident acknowledged that staff were expected to supervise the resident during meals and that the meal tray should not have been left with the resident. The certified nurse aide who delivered the meal tray also stated that the resident required supervision and that the nurse should have been notified when the resident refused to relinquish the tray. The facility's own policy on aspiration precautions required individualized care plans and supervision for residents at risk of aspiration, with interventions based on speech therapy recommendations. Despite these policies and the resident's documented needs, staff failed to provide the required supervision during meals, resulting in noncompliance with the care plan and physician's orders.