Failure to Follow Assisted-Feeding Care Needs Resulting in Aspiration Pneumonia
Penalty
Summary
The facility failed to prevent an accident and ensure safe supervision during feeding for a resident who was dependent on staff for all ADLs, including eating. Facility policies on Fall and Accident Prevention and Restorative Nursing-Eating/Swallowing required a safe environment free from hazards and specified that residents needing assistance with eating should be kept upright, observed for aspiration, and given small bites and sips. The resident’s MDS documented multiple sclerosis, chronic pain, depression, and anxiety, with the resident being alert, oriented, and fully dependent on staff for ADLs. The resident’s care plan and ECS documentation specified dependence on staff for eating and the need for upright positioning and monitoring for aspiration. On the identified dinner meal, the resident began coughing, felt food was stuck, and had difficulty breathing while being fed by a CNA. Nursing notes documented choking and vomiting of food, followed by physician notification and diagnostic testing that led to treatment for pneumonia and then aspiration pneumonia, including antibiotics, respiratory treatments, and oxygen as needed. During an interview, the resident reported that at the time of the choking event the head of the bed was too flat compared to the current 45-degree elevation, and expressed distress about the incident. In a separate interview, the CNA who fed the resident stated the resident had been positioned “damn near 90 degrees,” attributed the coughing to talking while eating, and admitted not knowing where to find the resident’s specific care needs for eating, only knowing the resident as a “feed.” Other CNAs interviewed were able to locate and describe the resident’s eating-related care needs in the ECS. The Nursing Home Administrator confirmed the facility failed to prevent an accident that resulted in actual harm of aspiration pneumonia for this resident.
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