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F0689
D

CNA Fell Asleep During Feeding, Failing to Supervise Resident with Dysphagia Risk

Houston, Texas Survey Completed on 04-24-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a certified nursing assistant (CNA) fell asleep while providing feeding assistance to a resident with severe cognitive impairment and multiple medical conditions, including dementia, malnutrition, atrial fibrillation, osteoporosis, diabetes, and hypertension. The resident required supervision or touching assistance for eating and had recently been evaluated for dysphagia, with recommendations for close supervision during oral intake. Despite these needs, the CNA was observed on video footage sleeping in a chair next to the resident during lunch, with her eyes closed and head nodding, while the resident was left unattended. During the incident, the resident began coughing while the CNA remained asleep and did not respond to the resident's distress. The video showed the resident covering her mouth and waving her hand to indicate she did not want more food, but the CNA did not wake up or check on her. Another resident in the room attempted to alert the CNA by calling out, but the CNA only briefly woke up, smiled, and then resumed sleeping. The CNA's inattention persisted throughout the meal period, and she attempted to feed the resident again after waking, despite the resident's refusal. Interviews with staff and residents confirmed that the CNA fell asleep multiple times while assisting with feeding and failed to respond when the resident coughed. The resident's care plan required close supervision during meals, and the facility's policies emphasized the need for necessary services to maintain good nutrition and health. The failure to provide adequate supervision during feeding placed the resident at risk, as documented by the survey findings.

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