Failure to Follow NPO Care Plan Resulting in Resident Harm
Penalty
Summary
A deficiency occurred when the facility failed to follow the care plan for a resident who was designated as nothing by mouth (NPO) due to multiple diagnoses, including pneumonia, dysphagia, respiratory failure with hypoxia, and cognitive communication deficit. The resident's care plan, initiated on 10/16/2025, specified the use of a gastrostomy tube for nutrition and water flushes as ordered, with a physician's order confirming NPO status. Despite these documented interventions, the resident was observed with a food tray and food in his mouth, specifically three shrimps, on 11/15/2025. The incident was documented in the electronic medical record, and the kitchen staff was subsequently educated about the resident's NPO status. Following this event, the resident experienced a significant change in condition, including decreased oxygen saturation and respiratory distress, which required escalation of oxygen therapy and eventual transfer to the hospital. Hospital records indicated the resident was admitted with acute respiratory distress, hypoxic respiratory failure, and required intensive care interventions, including thoracentesis and ventilatory support. The Director of Health Services confirmed that the resident's NPO restriction was documented in the care plan and acknowledged that the care plan was not followed when the resident was given a food tray.