Failure to Prevent Access to Incorrect Meal Tray for Resident at Aspiration Risk
Penalty
Summary
Facility staff failed to ensure that a resident at risk for aspiration, who required 100% feeding assistance, was not left with a breakfast tray within reach. During a facility tour, a breakfast tray intended for another resident was observed on the bedside table next to the resident at risk, with no staff present in the room. The resident's medical record indicated diagnoses including metabolic encephalopathy, dysphagia, obesity, hearing loss, and a gastrostomy, with dietary orders specifying a mechanical soft diet and enteral feeding, along with strict aspiration precautions and the need for full assistance with feeding. Interviews with staff revealed a lack of awareness regarding the placement of the breakfast tray and the associated risks. The CNA interviewed was unaware of the situation and could not articulate the dangers, while the RN and DON acknowledged the potential for serious harm if the resident consumed the incorrect meal. Facility policy required staff to verify correct diet trays before serving, but this protocol was not followed, resulting in the deficiency.