Failure to Provide Required Supervision and Assistance During Meals
Penalty
Summary
A resident with diagnoses including dysphagia and partial paralysis to the left side was admitted to the facility and had a physician order for 1:1 supervision during meals, cues to slow eating, and pre-cut food into bite-sized pieces. Observations revealed that the resident was left unattended during meal times, with staff delivering meal trays, positioning the resident, and then leaving. On two separate occasions, the resident was found alone with her meal tray, without the required supervision or assistance. A review of the resident's electronic record showed no documentation of 1:1 supervision for meals over the past 30 days, despite the physician's order. When requested, the facility was unable to provide a policy and procedure defining levels of meal assistance. The facility's existing policies indicated that residents should receive meal assistance according to their individual needs and that physician orders should be followed as prescribed. The nurse practitioner confirmed that staff are expected to follow orders for resident safety.