Failure to Provide Safe Feeding Assistance and Ordered Liquid Consistencies
Penalty
Summary
The facility failed to provide safe feeding assistance for two residents who required help with eating, resulting in both being put at risk for aspiration. For one resident with severe cognitive impairment, dysphagia, and a recent diagnosis of aspiration pneumonia, staff did not follow the speech therapist's recommendations for honey-thick liquids to be given by teaspoon. During a meal observation, the certified nursing assistant (CNA) provided large sips of milk directly from a cup, did not verify the correct liquid consistency, and gave multiple heaping spoonfuls of food in rapid succession without ensuring the resident had swallowed each bite. The CNA also mixed applesauce with other foods without authorization and failed to recognize or report signs of aspiration, such as coughing and gulping, during the meal. Another resident, also dependent on staff for eating and with a history of recurrent pneumonia and dysphagia, was not provided with the ordered nectar-thick beverages during a breakfast meal. The CNA assisting this resident failed to add thickener to the cranberry juice and was unsure if thickener had been added to other beverages. The CNA admitted to forgetting to thicken the cranberry juice and only realized the omission after the meal was completed. The nurse and nurse consultant confirmed that staff are responsible for ensuring liquids are thickened according to physician orders and acknowledged that providing incorrect liquid consistency could pose a risk for aspiration. Both incidents were observed and confirmed through interviews and record reviews. The facility's policies required staff to check diet slips, provide appropriate food and liquid consistencies, and monitor for signs of aspiration. However, these protocols were not followed, and staff demonstrated a lack of understanding of the specific feeding techniques and precautions required for residents with dysphagia. The deficiencies were directly related to staff actions and inactions during meal assistance, as well as a lack of adherence to individualized care plans and physician orders.