Failure to Provide Required Supervision During Mealtimes
Penalty
Summary
The facility failed to provide required supervision during mealtimes for three residents who needed assistance or monitoring while eating. Observations showed that these residents, who had diagnoses such as cerebral palsy, dementia, malnutrition, progressive neurological conditions, Alzheimer's disease, Parkinson's disease, cancer, and heart failure, were left unsupervised in the dining room during breakfast. Staff were not present in the dining room for several minutes while residents were eating, despite the residents' care plans indicating a need for supervision or assistance with eating. One resident was observed coughing while eating, but no staff were present at that time to provide immediate assistance. Interviews with dietary and nursing staff confirmed that facility policy and expectations required a nursing assistant to be present in the dining room whenever residents were eating, to ensure safety and provide assistance if needed. Staff acknowledged that there were periods when no staff were present in the dining room during meals, and that this was not consistent with facility expectations. The facility was unable to provide a policy regarding dining supervision when requested.