Failure to Provide Required Meal Supervision for Resident with Dysphagia
Penalty
Summary
The facility failed to provide adequate supervision during meals for a resident with cerebral palsy and dysphagia, who was at risk for choking. The resident's medical record indicated a need for a regular texture diet with soft, bite-sized pieces and thin liquids with straws, as well as monitoring and supervision during meals to observe for choking, coughing, or holding food in the mouth. Despite these documented needs and care plan interventions, multiple observations showed the resident eating meals in the activity room without any staff supervision present. Interviews confirmed that nursing staff were unaware of the resident's swallowing precautions and did not provide the required supervision during meals. The resident reported relying on another resident for support during meals due to fear of choking and stated that staff did not monitor them while eating. Staff interviews further revealed a lack of awareness regarding the resident's dietary and supervision needs, resulting in the resident being left unsupervised during multiple meal times.