Failure to Provide Required Assistance and Supervision During Meals
Penalty
Summary
The facility failed to provide appropriate assistance and supervision with meals for five residents who required varying levels of support due to conditions such as dysphagia, muscle weakness, cognitive impairment, and other medical diagnoses. Observations revealed that residents who were care planned for supervision or assistance during meals were left alone, often in their rooms or in areas not visible to staff. In several instances, residents were observed eating with their hands, spilling food onto themselves, or not consuming all components of their meals, indicating a lack of necessary support. For example, one resident with moderate cognitive impairment and dysphagia was repeatedly left unsupervised during meals, resulting in significant food spillage and incomplete intake. Another resident with feeding difficulties and muscle weakness was observed eating alone in the day room without staff supervision, despite care plans indicating the need for supervision and adaptive equipment. Staff interviews confirmed that these residents were not being supervised as required, and staff often misunderstood or disregarded the care plans and Kardex instructions. In one case, a resident with severe cognitive impairment and total dependence for eating was left alone with a meal tray, did not initiate eating, and was later found eating with hands or not eating at all until prompted by staff much later. Documentation reviews, including care plans, Kardex, and physician orders, consistently indicated the need for supervision or assistance during meals for these residents. However, staff interviews revealed a lack of awareness or adherence to these requirements. The Director of Nursing confirmed that the expected standard was not met, as residents requiring supervision or assistance were left unsupervised or without the necessary help during meals, contrary to their documented care needs.