Failure to Provide Required 1:1 Feeding Assistance for Resident on Aspiration Precautions
Penalty
Summary
A deficiency occurred when a resident with a history of dysphagia, Alzheimer's disease, type 2 diabetes mellitus, and chronic obstructive pulmonary disease was not provided with the required one-to-one feeding assistance during lunch. The resident was observed eating independently in bed with the head of the bed elevated, despite clear signage and dietary orders indicating the need for strict aspiration precautions and one-to-one feeding. The meal ticket, posted signage, and clinical records all specified that the resident required staff to feed her, using small spoonfuls and ensuring the mouth was cleared before offering additional bites, and that the resident should not be left alone with the meal tray. Further interviews confirmed that the speech pathologist had discharged the resident from therapy with recommendations for mechanical soft solids, thin liquids, and full staff assistance with feeding, emphasizing the risk of choking or aspiration if not assisted. The care plan also documented the need for partial to moderate assistance and one-to-one feeding. When the surveyor requested the facility's policies and procedures for aspiration precautions and ADL care, the administrator stated that no such policies existed.