Failure to Provide Supervision and Appropriate Diet During Meals
Penalty
Summary
The facility failed to ensure adequate supervision and accident prevention for three of nine sampled residents, specifically in the areas of nutrition and fall prevention. One resident with a history of cerebral infarction, hemiplegia, severe cognitive impairment, and dysphagia was not supervised during meals as required by her care plan. Despite being on a mechanically altered diet due to swallowing difficulties, she was served a whole hot dog by a CNA, which she consumed without staff supervision. The resident had also previously been given inappropriate foods such as potato chips and Goldfish crackers by staff, contrary to her dietary requirements. Observations and record reviews revealed that the resident's care plan and physician orders specified the need for a mechanically altered diet and supervision during meals to monitor for signs of aspiration or choking. However, documentation in the electronic medical record showed no evidence of supervision being provided during meals over a two-week period. During direct observation, the resident was left alone with her meal and was not monitored by staff, even when she was offered and consumed foods not consistent with her prescribed diet. Interviews with staff confirmed that the CNA provided the resident with a whole hot dog and did not ensure it was prepared according to the resident's dietary needs. The dietary manager was unaware that the hot dog was for this resident and confirmed that no ground hot dogs were prepared that day. Further, the resident was observed eating without supervision on another occasion, and staff interviews indicated a lack of adherence to protocols for verifying diet orders and providing required supervision during meals.