Failure to Prevent Ingestion of Foreign Object in Cognitively Impaired Resident Requiring Meal Supervision
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision to prevent accidents for a resident with dementia and known intrusive and rummaging behaviors. Facility policies on Safety and Supervision of Residents and Meal Supervision and Assistance required an environment as free from accident hazards as possible and adequate supervision during meals. The resident’s ADL care plan required supervision when eating, and the behavior care plan documented intrusive and rummaging behaviors, indicating a need for close monitoring, particularly around items that could pose a hazard. On the day of the incident, the resident, who had diagnoses including stroke, schizophrenia, anxiety, and dementia, was assisted with lunch in their room by a CNA. The CNA reported that the resident became drowsy during the meal and stated they did not want to eat anymore. The CNA then moved the food tray out of the resident’s reach by pushing it across the room, stated that all covers and wrappings were removed from the room, and left the resident alone to assist another resident, despite the care plan requirement for supervision when eating and the resident’s cognitive impairment and rummaging behavior. Shortly thereafter, another CNA found the resident lying face down on the floor and called for help. A nurse responded, found the resident unresponsive with vomit under them, and initiated a Code Blue and CPR. Suctioning by nursing staff removed a white substance resembling mashed potatoes from the airway. The resident was transferred to the hospital by 911, where paramedics continued CPR and, during attempted intubation, removed a foreign body from the airway that appeared to be a piece of plastic wrap with food inside. The DON later stated the facility could not identify where the plastic wrap came from or how the resident obtained it, despite the expectation that the resident was supervised at all times when eating, and acknowledged the resident should not have been able to get or ingest plastic wrap.
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