Failure to Manage NPO, Food-Seeking Resident on G-Tube Feeding
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, care plan, implement interventions, and provide supervision for a resident who was NPO and dependent on G-tube feedings, despite known food-seeking behaviors and severe cognitive impairment. The resident’s admission MDS documented severe cognitive impairment, dependence on staff for ADLs, incontinence, and G-tube nutrition, with NPO status due to dysphagia and a history of silent aspiration. On 2/19, the care plan and a risk-versus-benefit form identified that the resident self-sought food and fluids while NPO, required reminders and redirection, and was at risk for aspiration, pneumonia, loss of airway, hospitalization, and possible death if consuming oral intake. The RD documented that the resident was self-seeking food and fluids, had impaired cognition, and could not repeat back understanding of the NPO education, and an order was added to the TAR to observe for self-seeking food and provide re-education as needed. Subsequent clinical notes showed ongoing concerns that the resident was eating and drinking despite strict NPO orders. On 2/25, the NP documented that staff reported continued food- and fluid-seeking, and the resident nodded yes when asked if she was eating or drinking; a chest X-ray was ordered, which was normal. On 3/4, the NP again documented silent aspiration, cough, coarse lung sounds, and that the resident continued to report oral intake despite strict NPO, and another chest X-ray was ordered and read as normal. An email exchange on 2/24 showed the IDT was aware of the resident’s low SLUMS score indicating dementia, wandering, and the need for a memory care bed, but no new interventions were established beyond continued monitoring when no memory care bed was available. Staff interviews and documentation revealed multiple unaddressed episodes of food-seeking and wandering into areas where food was present. A staff member reported seeing the resident eating a gummy jolly rancher given by another resident and observing her wandering into other residents’ rooms and attempting to eat food from leftover trays, as well as being in the dining room during and after meals; the record lacked evidence of any action taken in response to these events. Another staff member also reported seeing the resident wandering all over the unit and in the dining room during and after meals. The SLP stated the resident had severe cognitive deficits, wandered around the unit, did not understand what NPO meant, and was at high risk for aspiration if she ate regular food or fluids, based on a prior hospital video swallow study recommending NPO. The NP later stated she was never informed about the resident eating gummy candy and would have expected immediate notification for further assessment and monitoring. Ultimately, the resident was found unresponsive with heavy breathing and a very high temperature, was sent to the ED, and was diagnosed with acute hypoxic and hypercarbic respiratory failure with aspiration pneumonia; large food material was suctioned from the oropharynx, and the resident required intubation and CPR for a brief cardiac arrest. The surveyors concluded that the facility failed to assess, develop, and implement appropriate interventions and supervision for this known NPO, food-seeking resident, resulting in an immediate jeopardy situation.
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