Failure to Prevent Accidents and Ensure Dietary Supervision
Penalty
Summary
The facility failed to adequately assess a resident following an unwitnessed fall and did not provide sufficient supervision to prevent another resident from consuming food not included in their prescribed diet. In the first incident, a resident with diagnoses including paranoid schizophrenia, major depressive disorder, and pseudobulbar affect, who was cognitively intact and required supervision for ADLs, was found lying on the ground near the nurse’s station with her walker beside her. A housekeeper assisted the resident off the floor without notifying nursing staff, and the LPN on duty was unaware of the incident until informed by the surveyor. The required post-fall assessment and reporting procedures were not initiated immediately following the event. In the second incident, a resident with Alzheimer’s disease, dementia, oropharyngeal dysphagia, and schizoaffective disorder, who was on a pureed diet, was observed taking and consuming regular texture food from other residents’ trays on multiple occasions. Despite documentation of repeated incidents where the resident took food from trays or the trash and consumed it, staff interventions were limited to verbal redirection and education. During an observation, the resident was able to access the tray cart, remove bacon from another resident’s tray, and begin eating it before being stopped by a staff member. Interviews confirmed that staff were aware of the resident’s behavior but had not implemented additional interventions to prevent access to inappropriate foods. Both incidents demonstrate a lack of adequate supervision and failure to follow established protocols for resident safety and dietary management. The facility did not ensure that staff were consistently monitoring residents at risk for falls or for consuming foods not aligned with their prescribed diets, resulting in deficiencies affecting two residents reviewed for accidents.