Failure to Implement Feeding Interventions for Dependent Resident
Penalty
Summary
A deficiency occurred when staff failed to implement appropriate interventions for a resident who was dependent on staff for eating and had multiple diagnoses, including dementia, dysphagia, mood disorder, lack of coordination, and difficulty waking. The resident's care plan and Kardex directed staff to assist or feed as needed, use a slow approach with cues, encourage fluid intake, and, if the resident became resistive, to postpone care and re-approach after allowing time to regain composure. Physician orders specified a dysphagia puree diet with nectar thick liquids, and the resident was documented as having severely impaired cognitive skills, being dependent for all ADLs, and being non-ambulatory. On the date in question, video footage showed a nursing assistant feeding the resident and, when the resident attempted to block their face, the assistant moved the resident's hands away and continued feeding, ultimately pushing a spoon further into the resident's mouth and causing the resident's head to jerk. The assistant then abruptly ended the feeding and left the room. The Director of Nursing confirmed that the assistant should have stopped feeding, attempted redirection, and re-approached the resident as per the care plan. This failure to follow the established interventions and care plan led to the deficiency.