Failure to Provide Required Supervision and Assistance with Meals
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically supervision and cueing during meals, for two residents. One resident with severe dementia and chronic malnutrition was repeatedly observed alone in their room during breakfast, attempting to self-feed but dropping food and spilling liquids on themselves. Despite care plans and Kardex instructions requiring continual supervision and verbal cues during meals, staff were not present to assist or encourage the resident, resulting in significant food spillage and distress. Interviews with staff confirmed that the resident required total assistance and should not have been left alone during meals. Another resident with anoxic brain damage, aphasia, dysphagia, and a history of cerebral infarction was also observed eating alone in bed without staff supervision. This resident, who is cognitively intact but dependent on staff for ADLs and requires continual supervision and assistance with eating, was found with food and liquids spilled on their body and reported being in an uncomfortable position to eat. The resident was also observed coughing on fluids, and staff interviews confirmed that the resident was not receiving the required supervision during meals as outlined in their care plan and physician's orders. Both residents had care plans and Kardex instructions specifying the need for continual supervision and assistance with eating, including monitoring for signs of dysphagia and providing help with hot liquids. However, staff failed to follow these directives, leaving the residents unsupervised during meals and not providing the necessary cues or assistance, as confirmed by direct observation and staff interviews.