Failure to Provide Required Supervision for Aspiration Precautions
Penalty
Summary
The facility failed to implement care plan interventions for aspiration precautions for a resident with chronic respiratory failure and congestive heart failure. The resident's care plan required one-to-one supervision during all meals due to aspiration risk. On one occasion, the resident was found alone in their room with a partially eaten meal tray and no staff present, despite calling out for assistance. The speech therapist later confirmed the resident should have been under one-to-one supervision while eating and observed the meal tray unattended. The assigned CNA was unaware of the resident's need for supervised eating and stated it was their first shift working with the resident. The RCM also confirmed the resident's requirement for aspiration precautions and one-to-one supervision during meals.