Failure to Implement and Document Aspiration Precautions for Residents with Dysphagia
Penalty
Summary
The facility failed to ensure appropriate safety interventions were developed and implemented for two residents with dysphagia who were at risk for aspiration. For one resident with a history of stroke, heart failure, and facial weakness, observations showed that the resident was eating meals without assistance, despite care plan directives and physician orders for aspiration precautions and checks for oral pocketing after meals. Staff interviews revealed confusion and lack of awareness regarding the resident's swallowing issues and the required level of assistance, with some staff stating the resident did not require help and others indicating the care plan called for substantial assistance. Documentation and communication among staff were inconsistent, and the care plan was not consistently followed. For another resident with dysphagia and a feeding tube, the facility did not address the resident's refusal to comply with an NPO (nothing by mouth) order. The resident was observed eating food brought from outside and reported ordering and consuming regular food, despite a care plan and diet order indicating tube feeding only. There was a lack of documentation regarding the resident's refusal of the NPO order, absence of monitoring for aspiration risk, and no evidence that the physician or family/legal representative was notified. Staff were unaware of the resident's oral intake, and the care plan and Kardex were not updated to reflect the resident's non-compliance or the need for monitoring. The facility's policy required documentation of treatment refusal, notification of the physician and legal representative, referral to social services, and care plan updates when refusal or non-compliance occurred. However, these steps were not followed for the resident who refused the NPO order. The lack of appropriate interventions, monitoring, and documentation placed both residents at risk for aspiration and related health complications.