Failure to Provide Adequate Supervision to Prevent Choking and Falls
Penalty
Summary
A deficiency occurred when a resident with a history of swallowing difficulties and choking episodes was not adequately supervised during mealtimes. The resident, who had undergone a swallow study and had a care plan indicating the need for close monitoring, cueing, and food cut into small pieces, was observed coughing, struggling to keep food on her fork, and appearing drowsy during meals without consistent staff assistance. On multiple occasions, staff were not present in the dining room for periods of time, and the resident received cueing from another resident rather than staff. The care plan interventions were not consistently implemented, and there were no new interventions documented when the resident's diet was advanced, despite ongoing issues with coughing and choking. Another deficiency involved a resident at high risk for falls who sustained a fall resulting in major injury. The resident was found with a bruise and a wound after falling from a bed that had been raised to its highest position. Interviews revealed inconsistent accounts regarding how the resident accessed the bed remote, which was typically kept out of reach. Staff were unclear about the circumstances leading to the fall, and there was a lack of documentation and follow-through on new fall prevention interventions. The care plan and post-fall huddle documentation did not specify new actions to prevent future falls, and staff reported not receiving education or updates on fall prevention measures after the incident. Both deficiencies were supported by direct observations, staff interviews, and record reviews, which demonstrated lapses in supervision, inconsistent implementation of care plan interventions, and inadequate communication among staff regarding resident safety needs. The facility failed to ensure a safe environment by not providing adequate supervision to prevent accidents, including choking and falls, for residents identified as being at risk.