Failure to Provide Supervision During Meals for Resident with Behavioral Needs
Penalty
Summary
Staff failed to provide care and treatment as outlined in the care plan for a resident with dementia and dysphagia who required total assistance and supervision during meals. The care plan specified that the resident was to eat in a designated dining room under supervision due to an easy-chew diet and a history of behavioral issues, including agitation and verbal aggression. On one occasion, the resident and another individual engaged in a verbal altercation in the dining room, and it was confirmed that no CNA was present to supervise at the time, despite the care plan requirement. Multiple staff interviews revealed that there were several instances where no CNA was present in the dining room during meals, including during the incident involving the verbal altercation. Staff acknowledged that supervision was required for the resident's safety, but CNAs alternated supervision due to other responsibilities, leading to lapses in coverage. Facility leadership confirmed that staff should have been present to supervise the resident as outlined in the care plan.