Failure to Provide Adequate Supervision and Implement Aspiration Precautions
Penalty
Summary
The facility failed to provide adequate supervision and implement care planned interventions for multiple residents at risk for accidents, including those with a history of substance abuse and those requiring aspiration precautions. One resident with a known history of opioid abuse and a recent drug overdose was not sufficiently monitored, resulting in two separate incidents where the resident became unresponsive and required Narcan administration. Documentation revealed that the resident was able to save and self-administer multiple doses of pain medication, and also admitted to taking a Methadone pill provided by another resident. The care plan interventions were limited to offering substance abuse group attendance and support, without specific measures to prevent medication hoarding or unauthorized drug use. Another resident with hemiplegia, dysphagia, and dementia required 1:1 supervision with meals and strict aspiration precautions, as recommended by speech therapy and hospital discharge documentation. However, observations showed that this resident was left unsupervised during meals, both in their room and in the dining room, and was able to access and consume food and liquids without staff present. Staff interviews revealed confusion about the resident's dietary orders and supervision requirements, and the care plan did not reflect the most current speech therapy recommendations. The resident was observed coughing repeatedly during meals, a sign of aspiration risk, without immediate staff intervention. A third resident with a history of traumatic brain injury and dysphagia, who had transitioned from tube feeding to oral intake, was also not provided with the required 1:1 feeding assistance. Despite physician and speech therapy orders for ground solids, nectar thick liquids, and close supervision, the resident was observed eating unsupervised, taking large bites, and consuming thin liquids not consistent with their prescribed diet. Staff were not present to monitor or assist during meals, and the resident experienced coughing episodes indicative of aspiration risk. Facility policies on aspiration precautions and therapeutic diets were not consistently followed, and staff were not always aware of or implementing the required interventions.