Failure to Provide Adequate Mealtime Supervision for Residents at Aspiration Risk
Penalty
Summary
Surveyors identified that the facility failed to provide adequate supervision during mealtimes for multiple residents with a history of aspiration and dysphagia. For one resident with diagnoses including dysphagia, blindness, and Alzheimer's dementia, physician orders and care plans required direct supervision during meals, including verbal cues and alternating solids with liquids. However, the resident was observed eating alone in their room without staff present, and the assigned nurse aide left the resident unsupervised. Interviews revealed inconsistencies in staff understanding and communication regarding the required level of supervision, and the dietary report did not include the necessary supervision and feeding guidelines as required. Another resident with severe cognitive impairment and dysphagia was observed eating alone in their room without assistance or supervision, despite orders for intermittent distant supervision and assistance with cutting food into bite-sized pieces. The dietary aide delivered the meal without knowledge of the resident's specific needs, and the tray ticket failed to indicate the required precautions and assistance. Nursing and dietary staff were unclear about their responsibilities, and the resident's care needs were not communicated effectively through the facility's documentation systems. A third resident, admitted with dementia and malnutrition, was also not provided the required supervision during meals. The resident was observed with a meal tray in front of them and no staff in eyesight, despite orders for distant supervision and aspiration precautions. Staff interviews confirmed a lack of awareness of the resident's supervision requirements, and the tray ticket did not reflect the necessary precautions. Facility documentation and communication breakdowns contributed to the failure to ensure appropriate supervision and adherence to aspiration precautions for residents at risk.