Failure to Follow Care Plan for Pureed Diet and Aspiration Precautions
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff followed a resident’s person-centered care plan and Resident Care Card (RCC) regarding a prescribed pureed diet and required monitoring for aspiration. The resident had dementia, COPD, dysphagia, severe short- and long-term memory deficits (BIMS score of 2), was dependent on staff for eating, and was identified as at risk for weight loss, wandering, and elopement. The care plan and RCC directed a regular, pureed texture diet with thin liquids, cues to eat slowly, maintaining an upright position after meals, offering snacks between meals and at bedtime as appropriate, monitoring during meals for aspiration, and removing food from the whole room due to the resident’s tendency to seek food from the roommate. Physician’s orders also specified a regular, pureed texture diet with thin liquids. Despite these directives, staff actions and inactions led to the resident accessing and consuming food inconsistent with the prescribed diet. During the night shift, the resident habitually wandered the hallway looking for food and had previously attempted to take food from the dirty food cart and had taken a bite of a sandwich from the cart, but the NA who observed these behaviors did not report them to a nurse, believing staff were already aware. The NA was not aware the resident was on a pureed diet and reported giving the resident snacks such as chocolate pudding during the night. On one occasion, the resident took a piece of a peanut butter sandwich from the food cart located outside the locked kitchen door and choked on it, requiring the LPN to perform the Heimlich maneuver to expel the sandwich. The DON later stated she was unaware of the prior incidents with the food cart and that the NA should have reported them, while facility policy directed that staff follow the plan of care and Care Card.
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