Failure to Protect Resident from Abuse During Feeding
Penalty
Summary
A deficiency occurred when a resident with dementia, dysphagia, mood disorder, and severe cognitive and physical impairments was not protected from abuse during mealtime assistance. The resident required total assistance with eating and was to be fed slowly, with cues and redirection if resistive. During a breakfast meal, video footage showed a nursing assistant (NA) attempting to feed the resident, who raised their hands to block their face. Instead of stopping or redirecting as care plans directed, the NA moved the resident's hands away and forcefully placed a spoonful of oatmeal into the resident's mouth, causing the resident's head to jerk. The NA then verbally accused the resident of kicking, despite no evidence of such behavior, and abruptly ended the feeding by throwing the spoon and leaving the room. Facility documentation and interviews confirmed that the NA did not follow the resident's care plan, which required postponing and reapproaching care if the resident became resistive. The actions observed in the video were identified by facility leadership as mistreatment and not in accordance with established policies to prevent abuse. The incident was substantiated through direct observation and review of the resident's care requirements and staff responsibilities.