Failure to Follow Speech Therapy Swallowing and Supervision Recommendations During Meals
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure a safe, hazard‑free environment and adequate supervision during meals for residents with specific speech therapy swallowing and positioning recommendations. Facility policies on Activities of Daily Living and Assisted Nutrition and Hydration required care and services to be based on comprehensive assessments, including appropriate assistance with eating and adherence to therapeutic diets and monitoring needs. Despite these policies, staff did not consistently follow speech therapy guidance or provide the ordered level of supervision and positioning during meals for two residents with cognitive impairment and dysphagia‑related needs. For one resident with mild cognitive impairment, neurogenic bladder, malnutrition, cerebellar ataxia, dysphagia, muscle weakness, and a documented dependence on staff for eating, the MDS showed the resident was dependent with eating and receiving speech therapy. A speech therapy evaluation documented that this resident required 1:1 feeding assistance, supervision for swallow safety 91–100% of the time at meals, and skilled ST three times a week to address swallowing and communication deficits. Physician orders included a regular diet with thin liquids and nutritional supplements. However, on multiple observations, the resident was found lying prone in bed on his/her stomach, self‑feeding regular meals and liquids without staff present or monitoring. On one occasion, staff entered only after the meal to remove the tray, leaving food pieces under the resident; on another, the resident coughed loudly and harshly and spit out food while continuing to eat unassisted. The Director of Therapy and the speech therapist both stated they expected the resident to be up in a chair for meals when possible and to have oversight if eating on his/her stomach, and the Administrator and DON stated they expected staff to provide protective oversight during meals when ordered. For a second resident with moderate cognitive impairment, stroke, dementia, and anxiety, the MDS indicated a need for partial to moderate assistance with eating. The care plan identified a potential nutritional problem related to dementia and directed staff to provide dining assistance such as tray setup, cutting food, identifying items, and feeding as needed. A swallowing strategies sign posted in the resident’s room instructed staff to assist with cutting food and tray setup, provide supervision at mealtimes, maintain an upright position during meals, and ensure small bites, slow rate, and alternating food and liquids. Despite these instructions, surveyors observed the resident slumped in bed, eating ground sausage with fingers, with the meal tray on a bedside table and no staff supervision. On another observation, the ADON and a CNA positioned the resident in bed and set up the meal but then left the room, after which the resident again ate with fingers without supervision, while the swallowing strategies sign remained posted. A CNA, the speech therapist, and the DON each confirmed that staff were expected to follow the posted swallowing strategies, keep the resident upright, and supervise the resident during meals, which was not done during the observed meals.
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