F0656

D

Failure to Implement Ordered Supervision During Meals

Pensacola, Florida Survey Completed on 02-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement care plan interventions for supervision during meals for one resident. Observation on 2/19/26 showed signage above the resident’s bed stating “Supervised All meals,” and record review confirmed an order dated 2/1/26 for “Supervised all meals, monitor oral holding,” a diet order and communication from the speech pathologist with the same instruction, and a speech therapy evaluation indicating the patient requires supervision at mealtime. The resident’s care plan, initiated 2/4/26, also stated “Supervise for all meals.” The speech pathologist clarified that supervision with meals means staff must remain in sight of the resident for the entire meal and should not leave a meal tray with the resident alone. The Regional Nurse Consultant, acting as DON, stated her expectation that staff delivering the tray stay with the resident during the entire meal.

Despite these documented requirements, on 2/19/26 at approximately 12:45 PM, the resident was observed sitting up in bed feeding himself with no staff present, while the room door was open and the privacy curtain pulled. A CNA interviewed shortly afterward stated she was unaware the resident required supervision with all meals and acknowledged that the sign in the room means staff are to be with the resident while he eats. The Unit Manager reported that if a resident requires assistance or supervision with meals, there is usually an order or it will be listed on the care plan, and that CNAs and staff are informed during daily shift reports. Another CNA stated that such requirements would be indicated on the resident’s meal ticket. These observations and interviews show that, although the need for supervised meals was ordered, documented, and posted, staff did not consistently implement the supervision intervention during the observed meal.