F0684

D

Failure to Follow Skin Protection Orders and Meal Supervision Requirements Resulting in Harm

Naugatuck, Connecticut Survey Completed on 01-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow physician orders and the care plan for skin protection and positioning for one resident, and failure to provide required supervision and feeding assistance during meals for another resident. Resident #14 had diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the left side, dysphagia, diabetes, and was identified on the MDS as cognitively intact but dependent on staff for eating, showering, toileting, dressing, and transfers. The MDS and care plan documented that the resident was at risk for pressure ulcer development and required a pressure-reducing device for the bed and chair, a bed cradle at the bottom of the bed at all times, offloading boots to both feet at all times, and skin integrity checks every shift. Physician orders dated 12/2/25 mirrored these interventions, directing use of a bed cradle at all times and bilateral offloading boots with skin checks each shift.

Surveyor observations on multiple occasions showed that these orders and care plan interventions were not consistently implemented for Resident #14. On 12/30/25 in the morning, the resident was observed in bed with only one heel protector on the left leg, no bed cradle in place, and the sheets resting on the resident’s toes while the lower extremities were elevated on a pillow. Later that afternoon, the resident again was observed in bed without a bed cradle, which was instead on the floor by the dresser, and still only one heel protector on the left leg with sheets contacting the toes. On 12/31/25, the resident was again observed in bed without the bed cradle in place, the cradle remaining on the floor, and the right heel protector not in place while the sheets hit the resident’s toes. A nurse aide reported believing the resident was to wear only one heel protector with the other foot elevated on a pillow and stated she did not know how to place the bed cradle on the bed and had never asked for instruction. She also reported never having seen a second heel protector in the room, despite the care card specifying bilateral offloading boots and a bed cradle at all times.

Interviews with licensed nursing staff and leadership confirmed awareness of the physician orders and the responsibility for oversight, but also confirmed that the orders were not followed. An LPN acknowledged that the orders required a bed cradle at the bottom of the bed and offloading boots to both feet at all times and that she was responsible for following physician orders and providing oversight, but she could not identify why this was not done. She also stated that the resident had a past history of skin breakdown and that the bed cradle and offloading boots were ordered for protection and prevention of skin breakdown. The DNS confirmed that the resident had orders for bilateral offloading boots and a bed cradle at all times and that the nurse on the unit was responsible for oversight. The DNS also indicated that the facility did not have a policy for heel protectors or bed cradles when one was requested.

The deficiency also includes the facility’s failure to ensure that meal supervision and feeding assistance were provided in accordance with physician orders and the care plan for Resident #125, resulting in a choking incident. Resident #125 had diagnoses including dementia, COPD, and seizure disorder, and the care plan identified a potential for aspiration and weight loss due to missing teeth and unintentional weight loss. Interventions included encouraging dining room meals, providing a full feed to promote intake, giving verbal encouragement and attention to the meal task, ensuring the resident ate while upright and remained upright after meals, and promoting slow eating with small bites and thorough chewing. The MDS showed mild cognitive impairment and a need for substantial assistance with eating. Physician orders included a consistent carbohydrate regular diet with regular texture and thin liquids, and an order dated 12/6/25 directed assistance with all meals and a speech therapy consult for difficulties swallowing related to weight loss.

Speech therapy documentation indicated that Resident #125 had mildly extended mastication due to missing teeth but good oral clearance and no signs of aspiration, and required maximum verbal cues and supervision to improve oral intake due to frequent distraction. The SLP recommended supervision with meals to enhance intake and keep the resident on task and documented that staff had been educated on strategies to promote oral intake. The facility’s reportable event form and nursing notes described that on 12/6/25, staff observed the resident with sudden drooling of fluid and seizure-like activity while seated in a wheelchair in the room, with a piece of chicken falling from the resident’s mouth. Staff assessed the airway, noted the resident was breathing with some coughing, and initiated back blows and abdominal thrusts per facility policy. The resident remained breathing but unresponsive and was transferred to the hospital by EMS.

Further interviews and documentation clarified that Resident #125 was supposed to have meals supervised or be a full feed, with a staff member staying with the resident to assist feeding and provide cues, consistent with the care plan and SLP recommendations. Due to a respiratory outbreak, communal dining was suspended, and a nurse aide brought the lunch tray to the resident’s room, placed it on the bedside table, cut up the chicken, replaced the lid, and left the room to feed another resident, leaving the tray accessible while the resident was alone. Another nurse aide later observed the resident in the wheelchair with jerking motions and found the tray on the bedside table with the plate cover removed and small cut-up pieces of chicken on the plate. LPNs responding to the call for help observed the resident slumped forward, drooling with apparent food particles in the mouth, unresponsive but attempting to cough or breathe, and they performed abdominal thrusts and finger sweeps without dislodging visible food. EMS and hospital records documented that the resident was believed to have choked, lost pulses en route, and was found to have a large food bolus within the glottic opening that was removed during laryngoscopy, with subsequent cardiac arrest and death on 12/8/25. The DNS and regional nurse confirmed that the resident required supervised or full feed meals and that the nurse aide who delivered the tray had not reviewed the care card before the shift and left the tray despite the resident’s need for supervision.