F0689

J

Failure to Provide Required 1:1 Supervision and Safe Positioning During Meals for Aspiration-Risk Resident

Little Chute, Wisconsin Survey Completed on 01-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure adequate supervision, positioning, and use of assistive devices during meals for a resident with a known history of aspiration. The resident had diagnoses including quadriplegia, dysphagia, expressive aphasia, and anxiety, and required mechanically altered textures and thickened liquids. The resident’s comprehensive care plan, revised in late November, specified 1:1 supervision for all meals, encouragement of small bites and clearing the mouth before the next bite, sealing lips around the cup opening until swallowing was completed, use of a neck pillow for proper neck positioning for all meals, and upright positioning in a wheelchair for meals. The facility’s Dining Experience policy also required individuals to be positioned upright as close to 90 degrees as possible when eating in bed and to receive appropriate cueing and assistance to promote safe swallowing.

Prior to the surveyor’s observation, there were documented indications of swallowing and respiratory concerns that were not fully acted upon. On one date in November, a progress note recorded that the resident coughed and had food coming out of the mouth during lunch; staff elevated the head of the bed, assisted with finishing the meal, and provided cues for small bites and clearing the mouth, but the LPN who documented the event did not notify the physician and was unsure if anything further was done. The APNP later stated they had not been notified and would have wanted respiratory assessments at least each shift. In mid-December, the resident reported that their lungs felt funny, had crackles on lung assessment, vomited during the night, and later that day had abnormal vital signs and lung sounds with rhonchi, leading to transfer to the hospital. Hospital records showed the resident was treated for aspiration-related right lower lobe infiltrate and septic shock, and an OT evaluation there reiterated the need for upright positioning, one sip or bite at a time, alternating liquids and solids, and 1:1 supervision during meals.

Speech therapy documentation before and after the hospitalization reinforced the need for strict swallowing precautions. A speech therapy progress note in early December indicated the resident required prompting to improve oral containment and bolus management, with safety precautions such as upright posture emphasized to staff. A speech therapy evaluation at the end of December recommended pureed texture, honey-thick liquids, eating in a wheelchair with total supervision, and upright positioning during meals and for at least 30 minutes afterward. A treatment note in mid-January confirmed the resident remained on a pureed diet with honey-thick liquids and required total supervision while upright for meals. A videofluoroscopic swallow study reviewed by the speech therapist showed airway invasion by nectar-thick liquids and poor posture with inability to sense penetration/aspiration.

Despite these documented needs and care plan directives, on the morning of January 15 the surveyor observed the resident eating breakfast alone in bed with the head of the bed at approximately 45 degrees and without the prescribed neck pillow. The surveyor heard several deep, congested coughs before the resident’s airway cleared and then observed a large amount of food on the resident’s dignity cover and juice spilling from the right side of the mouth. No staff were present in the room or in the hallway, and the resident indicated that staff had not been in the room to assist or check since breakfast began and that staff did not usually sit in the room to provide supervision during meals. CNAs assigned to the wing reported that they assisted with meal setup and checked on the resident every 15–20 minutes, and the RN confirmed the resident should be directly supervised when eating, as indicated on the Kardex, but also stated the resident typically ate in the room. The DON verified that staff should be with the resident when eating in the room and should watch for signs and symptoms of aspiration. These observations and interviews demonstrated that the facility did not follow its own policy, the resident’s care plan, or therapy recommendations for 1:1 supervision, upright positioning, and use of a neck pillow during meals, leading to a finding of immediate jeopardy beginning on January 15.

Removal Plan

• Reviewed R2's care plan, dietary orders, and ST recommendations and made appropriate updates and revisions.
• Reviewed residents to identify those who require supervision, assistance, cueing, or monitoring during meals due to aspiration risk.
• Educated staff on R2's care plan and supervised meals and snacks for residents at risk for choking or aspiration.
• Instructed nursing staff to verify diet orders and supervision levels prior to serving meals, document the supervision provided, and report swallowing concerns and condition changes.
• Observed meal service to ensure compliance with supervision recommendations.
• Conducted record review and observation audits to ensure ST recommendations are documented in residents' care plans and followed by staff.