Failure to Provide Adequate Supervision and Accident Prevention
Penalty
Summary
Surveyors identified deficiencies in the facility's supervision and accident prevention practices for two residents. One resident with diagnoses including dysphagia, dementia, and acute respiratory failure was on aspiration precautions, requiring a mechanical soft diet, nectar thick liquids, no straws, and partial assistance at meals. Despite these orders and care plan instructions, the resident was observed left alone with their meal tray, not assisted as required, and provided a straw by staff. Multiple staff interviews confirmed a lack of clarity and communication regarding who was responsible for assisting the resident, and staff did not consistently follow the aspiration precaution protocols, including supervision during meals and avoidance of straws. Another resident, with a history of diabetic neuropathy, cataracts, obesity, and a documented risk for falls, did not have all planned fall interventions in place. Observations over several days showed that the resident's bed was not consistently in the lowest position, fall mats were not always in place as care planned, and the call light was frequently out of reach, sometimes on the floor under the bed. The resident reported being unable to get help when needed due to the inaccessible call light. Staff interviews revealed inconsistent understanding and implementation of the care plan interventions, with fall mats not always replaced after meals and the call light not reliably positioned within reach. The facility's failure to ensure adherence to individualized care plans and physician orders resulted in residents not receiving adequate supervision or the necessary interventions to prevent accidents. The lack of proper meal assistance and aspiration precautions for one resident, and the absence of required fall prevention measures for another, were directly observed and confirmed through staff interviews and record reviews.