Failure to Provide Direct Supervision During Meals for Resident with Dysphagia
Penalty
Summary
A deficiency occurred when a facility failed to provide adequate supervision to a resident with a history of dysphagia, dementia, and right-sided hemiplegia, who was at increased risk for aspiration and had experienced multiple choking episodes. Despite repeated incidents where the resident choked on food and required the Heimlich Maneuver, staff did not implement the Speech Language Pathologist's (SLP) recommendation for direct supervision during meals. The resident's care plan and documentation did not reflect any changes or additional interventions after the SLP evaluation, which specifically called for direct supervision with all oral intake. Staff interviews and record reviews revealed that although the resident was seated at the Nurses Station during meals, no specific staff member was assigned to provide direct, continuous supervision as recommended. Instead, supervision was informal and staff were often engaged in other tasks such as passing meal trays or administering medications. Multiple staff members, including nurses and CNAs, confirmed that there was no formal assignment for direct supervision, and the resident was only monitored from a distance or within earshot. The lack of direct supervision persisted even after several documented choking incidents, with no evidence that the SLP's recommendations were incorporated into the resident's care plan or daily routine. Ultimately, the resident experienced another choking episode during a meal, which resulted in death despite staff attempts to perform the Heimlich Maneuver. The facility's failure to ensure direct supervision as recommended by the SLP and required by the resident's condition led to the deficiency.