Failure to Provide Required 1:1 Feeding Assistance and Incomplete Incident Investigation
Penalty
Summary
A resident with severe cognitive impairment, dementia, and a history of significant weight loss was assessed as requiring 1:1 feeding assistance during meals, as documented in the care plan and physician orders. Despite this, the resident was left unsupervised with a meal tray during lunch in the dining room. The tray was placed in front of the resident without a staff member present to provide the required 1:1 assistance. Multiple staff interviews and documentation revealed that no one was directly assisting or supervising the resident at the time the choking incident occurred. The resident began to choke on corned beef, and the event was not immediately witnessed by staff assigned to provide feeding assistance. When the choking was noticed, staff responded with chest thrusts, back blows, suctioning, and oxygen administration, but the resident ultimately expired shortly thereafter. Interviews with staff, hospice personnel, and the resident's family indicated ongoing concerns and previous reports that the resident was not consistently receiving the required 1:1 feeding assistance, despite repeated notifications to facility administration. The facility's investigation into the incident was incomplete, lacking thorough documentation of staff interviews and a clear timeline of events. There was no evidence that all potential witnesses were interviewed or that a comprehensive root cause analysis was conducted. The facility's own policy required documentation and interviews for incidents and accidents, but these steps were not fully carried out. The failure to provide the ordered 1:1 feeding assistance and to conduct a thorough investigation contributed to the deficiency cited.