Failure to Provide Adequate Supervision and Aspiration Precautions During Meals
Penalty
Summary
A deficiency occurred when a resident with a history of aspiration pneumonia, hyperphagia, and dysphagia, who was on aspiration precautions and required 1:1 supervision during meals, was left unattended in the dining room. The resident's care plan and Kardex did not fully document the required aspiration precautions or specialized feeding techniques, and staff were not consistently informed or aware of the specific supervision and assistance needed. The resident was served a ground diet with honey thick liquids, but was able to access inappropriate food consistency from another resident's plate due to lack of supervision. During the meal, there were no licensed nurses present in the dining room, and certified nurse aides did not provide the required 1:1 supervision. The resident was observed on surveillance video reaching for and consuming food from a neighboring plate, then displaying signs of distress, including waving arms and banging on the chest, which went unnoticed by staff present in the dining room. Dietary and housekeeping staff saw the resident in distress but did not intervene or notify nursing staff. The resident remained unattended for an extended period, and was later found unresponsive. Interviews with staff revealed confusion and lack of communication regarding responsibility for supervision and the specific needs of the resident. The speech language pathologist had documented and verbally communicated the need for 1:1 supervision and specialized feeding strategies, but these were not incorporated into the care plan or visible to all staff. The lack of adequate supervision and failure to follow aspiration precautions directly led to the resident choking and subsequently being pronounced deceased after resuscitation efforts.
Removal Plan
- All staff were educated on Aspiration Precautions, Dining Supervision, and Notification of Change in Condition.
- The facility attestation documented 87% of staff were educated with a plan to educate the remaining staff prior to the beginning of their next work assignment.
- Staff interviews verified understanding and retention of education provided.