F0656

E

Failure to Include Safe Meal Positioning in Person-Centered Care Plans

Watsontown, Pennsylvania Survey Completed on 03-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop comprehensive, person-centered care plans that addressed safe positioning during meals for 19 of 32 residents identified as needing to be out of bed during meals for swallowing safety. The facility’s Comprehensive Care Plan Policy required that care plans describe services needed to attain or maintain each resident’s highest practicable well-being. However, review of clinical records and care plans showed that residents with diagnoses and conditions such as diabetes, brain cancer, dysphagia, history of difficulty chewing, poor dentition, altered texture diets, thickened liquids, and CVA-related nutritional problems did not have care plan interventions specifying safe meal positioning, including being out of bed or seated upright during meals.

For one resident admitted with diagnoses including diabetes, brain cancer, and dysphagia, a Speech Therapy discharge summary recommended the resident be out of bed for meals. The Director of Rehabilitation confirmed this resident needed to be out of bed and/or seated upright to consume meals safely. Despite this, the resident’s care plan for nutritional problems only directed staff to monitor for signs and symptoms of dysphagia and did not include interventions related to safe positioning for meals, and the Kardex lacked directions for assisting the resident out of bed for meals. Similar omissions were found for multiple other residents whose care plans addressed dysphagia, nutritional risk, inadequate oral intake, limited food acceptance, biting/chewing difficulty, altered texture diets, and potential chewing difficulties, but did not include specific interventions for safe positioning during meals.

Review of Kardexes for these residents consistently showed no directions for assisting residents out of bed for meals, even though a list from the Director of Rehabilitation identified 32 residents who required staff to ensure they were out of bed during meals for swallowing safety. Nurse aides reported that they rely on the Kardex, the electronic hallway kiosk, or a paper census sheet to determine residents’ positioning requirements for meals. The census sheet reviewed did not document meal positioning requirements, and the Kardex entries lacked this information. During interviews, the Nursing Home Administrator and the DON confirmed that resident care plans did not consistently include meal positioning requirements, which prevented nurse aide staff from having accurate information available to provide safe care, and acknowledged that the facility failed to develop person-centered care plans related to safe positioning during meals for 19 of the 32 identified residents.