Failure to Properly Position Resident During Meal Assistance
Penalty
Summary
Staff failed to ensure a resident with multiple complex medical conditions, including dementia, Parkinson's disease, hemiplegia, and a history of respiratory failure, was properly positioned in his Broda chair while being assisted with eating. The resident had recently transitioned from being NPO and dependent on tube feeding to receiving a mechanical soft diet with continued enteral nutrition. Physician orders and the care plan specified that the resident should be upright during oral intake to minimize the risk of swallowing complications. On two separate occasions, the resident was observed reclined in his Broda chair at approximately a 45-degree angle while being assisted with meals. Staff members, including a CNA and an activities staff member, provided assistance without ensuring the resident was in the required upright position. After realizing the improper positioning, one staff member adjusted the chair, but the resident had already been assisted with eating while reclined. Interviews with staff, including a CNA, a licensed nurse, and an administrative nurse, confirmed that the expectation was for the resident to be upright during meals to reduce the risk of choking or aspiration. Facility policy also directed staff to ensure residents were appropriately positioned during meals. The failure to follow these directives resulted in the resident being at risk for swallowing complications and possible aspiration during meal assistance.