Failure to Care Plan Resident's Preference for Eating Position
Penalty
Summary
The facility failed to develop and implement a person-centered care plan that addressed a resident's preference to eat while lying down, despite clear evidence of the resident's ongoing behavior and associated risks. Observations showed the resident eating meals in bed with the head of the bed only slightly elevated, resulting in the resident bending their neck to eat and experiencing coughing during meals. Signage above the bed instructed staff to ensure the resident was upright while eating and drinking, but the resident reported consistently eating in a reclined position and sliding down even when staff attempted to elevate the bed. The resident also stated that staff would pull them up, but they would slide back down, and this occurred at every meal. Interviews with staff revealed that both a CNA and an LPN were aware of the resident's preference to eat lying down and had educated the resident about the risks of choking and aspiration. However, neither staff member reported this preference or behavior to the Director of Nursing or management. The Director of Nursing confirmed they were not aware of the resident's eating position and that the care plan did not address the resident's preference or the associated risks. The facility was unable to provide a care plan that incorporated the resident's choice to eat while lying down, despite the resident's medical diagnoses of gastro-esophageal reflux disease and dyspepsia, and the facility's policy requiring care plans to reflect resident preferences and needs.