Failure to Prevent Resident Access to Restricted Foods and Ensure Supervision
Penalty
Summary
A deficiency occurred when a resident with diagnoses including dysphagia, idiopathic epilepsy, and profound intellectual disabilities was observed consuming potato chips unsupervised, despite a physician-ordered diet restricting such foods and requiring supervision with all oral intake. The resident's diet order specifically prohibited chips, bread, whole potatoes, and caffeinated beverages, and required supervision during meals. Observations on two occasions showed the resident self-propelling in a wheelchair throughout the facility while eating a bag of potato chips without staff supervision. Interviews with staff revealed that the resident had a history of taking restricted items from snack carts and other areas, and staff often struggled to retrieve these items from her. The facility did not have a policy related to this practice, and staff acknowledged the difficulty in preventing the resident from accessing restricted foods. The resident's care plan and dietary orders were not consistently followed, resulting in the resident consuming a restricted food item without the required supervision.