Failure to Supervise Memory Care Residents During Meals
Penalty
Summary
Staff failed to provide adequate supervision to residents in the memory care unit during meal times, resulting in residents being left unsupervised while eating. On two separate lunch meal observations, staff members served food to the residents and then left the dining room, leaving all residents, including one with dysphagia and dementia, without supervision. At various times, staff such as CNAs, LPNs, and QMAs entered the dining room briefly but did not remain to supervise the residents as they ate. There were periods when no staff were present in the dining room while residents were consuming food and beverages. A review of the medical record for one resident revealed diagnoses of dysphagia and dementia, with an assessment indicating the need for supervision or assistance with eating. A family member reported concerns about the lack of supervision during meals, expressing fear that a resident could choke. Interviews with staff and administration confirmed that staff were expected to remain in the dining room during meals, but this did not occur on the observed dates.