Failure to Prevent Accident Hazards During Feeding and Ambulation
Penalty
Summary
Two deficiencies were identified regarding accident hazards and supervision for two residents. For one resident with dementia, dysphagia, and diabetes, staff failed to provide feeding assistance at eye-level. Observations showed a CNA feeding the resident while standing to the side of the bed, rather than at eye-level, despite the resident's care plan and facility policy requiring close monitoring for signs of choking due to swallowing difficulties. Interviews with staff confirmed that being at eye-level is necessary to observe swallowing and prevent choking, and that this protocol was not followed during the observed feeding. For another resident with ataxia, a history of falls, and dementia, staff failed to ensure the use of non-skid socks while the resident was ambulating. The resident was observed propelling himself in a wheelchair and then walking in the hallway wearing regular socks without grips, contrary to the care plan and facility policy, which specified non-skid socks as a fall prevention measure. Staff interviews confirmed that the resident was at high risk for falls and should always wear non-skid socks or shoes when out of bed. Both deficiencies were supported by record reviews, staff interviews, and direct observations. Facility policies and care plans for both residents outlined the required safety measures, but these were not followed during the survey, resulting in the residents being exposed to potential accident hazards.