Failure to Provide Required 1:1 Supervision During Meals for Resident with Swallowing Difficulties
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and ensure safety to prevent accidents for a resident with significant swallowing difficulties and other complex medical conditions. The resident had physician orders for 1:1 supervision during all meals due to a history of dysphagia, hemiplegia, and other health issues that increased the risk of choking and aspiration. Despite these orders, multiple surveyor observations documented that the resident was left unsupervised during several meals, with staff either delivering trays and leaving or only providing setup assistance without remaining present for supervision. The facility's own policies required identification of hazards, implementation of interventions, and monitoring for effectiveness, including providing supervision as an intervention to mitigate accident risk. However, the resident's care card and comprehensive care plan were not updated to reflect the physician's order for 1:1 supervision, and there was confusion among staff, including the speech-language pathologist and dietitian, regarding the resident's required level of supervision. Interviews revealed that key staff members were unaware of the current physician orders, and documentation in the Treatment Administration Record indicated staff were signing off on supervision that was not actually being provided. Surveyor interviews and observations further highlighted a lack of communication and coordination among the interdisciplinary team regarding the resident's dietary and safety needs. The speech-language pathologist was not aware of the 1:1 supervision order, and the dietitian could not recall reviewing the relevant hospital paperwork or physician orders. The resident was observed eating without supervision on multiple occasions, contrary to the documented orders and facility policy, leading to the identified deficiency.