Failure to Prevent Accident Hazards and Inadequate Supervision for Aspiration Precautions
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not provide adequate supervision or assistive devices to prevent accidents for residents on aspiration precautions. Multiple residents with diagnoses such as dysphagia, dementia, and cognitive impairment were observed eating meals without the required supervision or assistance, despite care plans and physician orders specifying the need for direct supervision, upright positioning, and thickened liquids. In several instances, residents were left alone in their rooms while eating, were not properly positioned, or were given liquids that were not thickened as ordered, resulting in coughing and increased risk of aspiration. Staff interviews revealed a lack of awareness regarding which residents required aspiration precautions and inconsistent practices in meal preparation and supervision. Additionally, the facility's dietary and nursing staff did not consistently ensure that meal trays matched the prescribed diet consistencies. For example, one resident received regular coffee instead of thickened liquids, and staff were unaware of the resident's dietary needs. Observations showed that staff often left residents unsupervised during meals, even when care plans required direct supervision or assistance. Staff interviews indicated that supervision was sometimes limited to walking by rooms or peeking in, rather than providing the direct oversight required for residents at high risk of aspiration. The facility also failed to address physical hazards related to heating surfaces in resident areas. Radiator covers and heating units in multiple rooms and common areas were found to have surface temperatures well above 125 degrees Fahrenheit, with some exceeding 150 degrees. These hot surfaces were accessible to residents, including those with wandering behaviors, and were located near beds, dining tables, and common areas. Maintenance staff did not keep records of temperature checks and were unaware of the potential hazard, despite the proximity of residents to these hot surfaces.
Removal Plan
- Review of residents identified to be on aspiration precautions, medical records, physician orders and care plans.
- Educate nursing, dietary and therapy staff, unit clerks, and resident assistants on aspiration precautions, checking meal tickets against tray contents, how to properly supervise and assist residents on aspiration precautions, and the correct procedure for feeding and recognizing signs of aspiration. Complete and review post-tests.
- Director of Dietary (or designee) to review meal tickets during tray preparation, and licensed staff to verify the meal tickets against meal trays for accuracy prior to passing.
- Review lunch trays on units to ensure correct food item consistencies, and interview staff to verify knowledge of the process.
- Review unit binders containing lists of residents on aspiration precautions and guidance on diet consistencies.
- Observe kitchen/dietary staff preparing thickened liquids before meal trays leave the kitchen.
- Review the facility's Aspiration policy.
- Ensure trays of residents on aspiration precautions arrive separate from other trays (per the facility's removal plan) and inform staff of the new process. Interview staff to verify knowledge of the new process.
- Observe staff supervising and assisting residents on aspiration precautions with meals.