Failure to Follow Safe Swallowing Precautions and Incomplete Monitoring After Change in Condition
Penalty
Summary
The facility failed to provide care in accordance with professional standards of practice for two residents. For one resident with diagnoses including subdural hemorrhage, Alzheimer’s disease, dementia, muscle weakness, and dysphagia, the care plan and speech language pathology (SLP) evaluation required safe swallowing precautions, a puree diet, and maintaining an upright posture for more than 30 minutes after meals. Observations revealed that after a breakfast meal, the resident’s head-of-bed (HOB) was lowered to a flat position immediately after eating, contrary to SLP recommendations and facility policy. The staff member acknowledged that the HOB should have remained elevated after eating, even if the resident consumed only a small amount, but proceeded to lower the bed for comfort during range of motion exercises. The resident remained flat in bed for a period after eating, and the HOB was only slightly elevated after the exercises were completed. For another resident with dementia, psychosis, dysphagia, and generalized muscle weakness, the care plan required monitoring of food tolerance and oral intake by percentage at each meal, with interventions to prevent further weight loss. The resident experienced a significant weight loss, triggering a change of condition (COC) and a requirement for 72-hour shift charting to monitor the resident’s intake and response. However, there was no documented evidence that this monitoring was completed for the required period. Progress notes did not reflect the necessary 72-hour monitoring, and staff interviews confirmed that the required documentation and monitoring were not performed. Facility policies required staff to promote safe swallowing through proper positioning and to document resident status and care, especially during changes in condition. The failure to maintain the resident’s HOB in an elevated position after meals and the lack of required 72-hour monitoring and documentation for a resident with significant weight loss demonstrate noncompliance with professional standards and facility policy.