Failure to Provide Appropriate Diet Consistency and Fall Prevention Measures
Penalty
Summary
The facility failed to provide appropriate diet consistency and supervision for a resident with oropharyngeal dysphagia and risk for aspiration. The resident was admitted with multiple diagnoses, including hemiplegia, aphasia, dementia, and oropharyngeal dysphagia, and had physician orders and a care plan specifying a pureed, nectar thickened liquid diet. Despite these orders, the resident was observed being served and consuming regular ice cream, a thin liquid, by an activity aide who was unaware of the resident's dietary restrictions and need for supervision. The speech therapist confirmed that the resident required nectar thick liquids and that plain ice cream was not appropriate, as it posed an aspiration risk. Additionally, the facility failed to implement and communicate fall prevention interventions for a resident identified as high risk for falls. This resident had a history of multiple unwitnessed falls and required maximal assistance for mobility and transfers. The care plan and physician orders specified that staff should assist the resident back to bed after meals and remove the wheelchair from bedside for safety. However, observations showed the resident's wheelchair was left next to the bed, allowing the resident to attempt unsupervised transfers. Staff interviews revealed inconsistent understanding of fall risk signage and interventions, with some CNAs unaware of the resident's fall risk status or the meaning of the signage on the doorframe. The facility's policies required adherence to physician orders and individualized fall prevention interventions, including clear communication among staff regarding residents' risks and required precautions. Despite these policies, the observed failures in following dietary orders and fall prevention interventions resulted in deficiencies related to accident hazards and inadequate supervision.