Failure to Supervise High-Risk Resident and Follow Aspiration Precautions
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision for residents at risk for accidents, including falls and aspiration. One resident (R1) had diagnoses of Alzheimer’s disease, dementia, anxiety disorder, weakness, and a prior right femoral neck fracture, and her active care plan identified cognitive impairment, extensive ADL assistance needs, use of a mechanical lift for transfers, and high fall risk, with interventions including prompt response to assistance requests and use of bed and chair alarms. On the day of the incident, multiple notes documented that R1 was extremely restless, anxious, and repeatedly attempting to stand from her wheelchair, with staff keeping her at the nurses’ station or taking her room to room to keep her in sight, and that her chair alarm was described as “not very loud.” Despite these known risks and behaviors, R1 was left unsupervised at the nurses’ station when a CNA took another resident to the bathroom and asked another CNA to watch R1; that CNA left the area, and R1 was subsequently found on the floor in the hallway by staff and another resident, bleeding from the back of her head and unable to move her right leg. The RN responding to the incident stated that the nurse assigned to the unit was on lunch break and she did not know where the other unit staff were at the time of the fall. Hospital records following the incident documented that R1 complained of severe right hip and knee pain, with imaging confirming an acute, moderately displaced right femoral fracture requiring surgical intervention. The facility also failed to follow speech therapy and hospital transfer recommendations for another resident (R46) at risk for aspiration. R46, admitted with Parkinson’s disease and dementia, had hospital speech pathology and dysphagia treatment plan documents specifying that he required 1:1 feeding assistance, should not use straws due to aspiration risk, and should continue SLP services and swallowing monitoring. Observations over multiple days showed R46 in his room and at meals with Styrofoam cups containing liquids and straws in them, both on his bedside table and on his meal trays, despite these written precautions. The DON and Director of Therapy acknowledged that staff were expected to follow hospital transfer recommendations and that, until evaluated by the facility speech therapist, the no-straw precaution should have been maintained, and the facility speech therapist later confirmed that his evaluation also recommended no straws for R46’s safety.
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