Failure to Provide Adequate Supervision During Meals Resulting in Resident Injury
Penalty
Summary
The facility failed to provide adequate supervision to prevent injury for a resident who required assistance during meals. The resident, who had diagnoses including COPD, muscle weakness, and was recovering from joint replacement surgery, was assessed as needing supervision for eating. Clinical documentation indicated that the resident experienced confusion, lethargy, tremors, and was below her baseline prior to the incident. Despite these symptoms, the care plan did not specify the required assistance level during meals, and the resident was served a hot soup meal without additional supervision. As a result, the resident spilled hot soup onto her lap, causing a burn to her thigh. Staff interviews confirmed that the resident had been exhibiting symptoms such as confusion and tremors before the incident, but no increased supervision was provided at the time the hot soup was served. The deficiency was identified through review of clinical records, progress notes, and staff interviews, which documented the resident's condition and the lack of appropriate supervision during meals.