F0811

D

Failure to Provide and Document Required Feeding Assistance and Intake Monitoring

Santa Monica, California Survey Completed on 03-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its policy and procedures for assisting residents with in-room meals, including providing needed feeding assistance, documenting meal intake, and ensuring appropriate reporting of decreased intake. For three cognitively impaired residents with significant functional limitations, staff did not consistently assist with feeding as required by their assessments and care plans, nor did they document meal intake percentages as directed. The facility also failed to ensure that a CNA notified licensed nursing staff when a resident had decreased meal intake.

Resident 1 was admitted with multiple diagnoses including metabolic encephalopathy, dementia, diabetes, muscle weakness, anemia, hypertension, a pressure ulcer, and GERD. The MDS showed cognition was not intact and that Resident 1 required maximal assistance with eating and was dependent for toileting, showering, and transfers. A nutrition assessment indicated total assistance was required for eating, and the care plan identified decreased self-feeding abilities related to metabolic encephalopathy and dementia, as well as nutritional risk with an intervention to document PO intake at every meal. On observation, Resident 1 was found lying flat in bed with eyes closed, chewing with orange material in the mouth and on the lips, and a half-eaten piece of potato on the sheet next to the face. The meal tray was on the bedside table with the cover still on; the plate contained mostly uneaten food and an unopened juice. CNA 1, who was assigned to Resident 1 and stated this was the first time caring for this resident, did not begin feeding until later, after being redirected to assist other residents in the dining room, and there was no documentation of meal intake for Resident 1 on the cited date, nor evidence that decreased intake was reported to an LVN.

Resident 3 had diagnoses including right-sided hemiplegia/hemiparesis, encephalopathy, UTI, COPD, diabetes, muscle weakness, aphasia, dysphagia, hyperlipidemia, anxiety disorder, and hypothyroidism, with an MDS indicating cognition was not intact and that supervision or touch assistance was required with eating. The care plan identified nutritional risk with an intervention to document PO intake at every meal, and a physician order specified a fortified regular pureed diet, level 4 texture, thin consistency, and that the resident was a feeder. Meal intake documentation for the referenced date showed “resident not available.” Resident 4, with hemiplegia/hemiparesis after cerebral infarction, asthma, epilepsy, protein-calorie malnutrition, muscle weakness, dysphagia, UTI, aphasia, hyperlipidemia, and hypertension, also had impaired cognition and required moderate assistance with eating. The care plan for Resident 4 included documenting PO intake at every meal, yet the same date’s intake record also indicated “resident not available.” Interviews revealed that CNA 1 was simultaneously assigned to Residents 1, 3, and 4 and was pulled to the dining room to assist Residents 3 and 4 when no restorative nursing assistants were present, leaving Resident 1 without timely feeding assistance and contributing to the lack of proper intake documentation and reporting for all three residents.

Staff interviews further clarified the breakdown in supervision and adherence to policy. CNA 1 reported starting to feed Resident 1 but being told to go to the dining room to assist Residents 3 and 4, who also needed feeding assistance, and only returning later to finish feeding Resident 1. LVN 1 confirmed that Resident 1 required assistance with feeding and stated that CNA 1 did not request help or report any decreased intake, despite the expectation that CNAs report intake of less than 50% and complete a “stop and watch” form. The RNA stated that there are usually three RNAs assigned to the dining area to pass trays and feed residents, but on the day in question one RNA had called off and the remaining RNA was sent out with another resident to an appointment and did not return until mid-afternoon, leaving the dining room without RNA coverage. LVN 2 observed there were no RNAs in the dining room and that CNAs were taking residents back to their rooms. The ADON later explained that one RNA had called off and the other was at an appointment, and that charge nurses were expected to monitor whether residents needing feeding assistance were being helped and to supervise CNAs, including adjusting assignments when a CNA had multiple residents requiring feeding assistance. Despite these expectations and the written policy on assisting residents with in-room meals and documenting intake, the facility did not ensure that Residents 1, 3, and 4 were assisted with feeding as care planned, that their meal intake percentages were documented, or that decreased intake for Resident 1 was reported to licensed nursing staff.

The facility’s written policy on assisting residents with in-room meals required staff to review the resident’s care plan, ensure appropriate positioning and preparation for meals, assist residents as necessary while encouraging self-feeding, and document the date and time of the procedure, the staff involved, the percentage of the meal consumed, the resident’s participation, and any special requests. Observations and record reviews showed that these steps were not followed for the three residents on the date in question. Resident 1 was not positioned upright as specified in the policy when first observed with food in the mouth and on the bed, and the tray remained covered and largely uneaten until CNA 1 returned. For Residents 1, 3, and 4, the required documentation of meal intake percentages was either missing or recorded as “resident not available,” and there was no evidence that CNA 1 notified an LVN or RN of Resident 1’s decreased intake, contrary to facility expectations and the care plan interventions.

These combined observations, interviews, and record reviews demonstrate that the facility did not implement its own policy and procedures for assisting residents with in-room meals and did not ensure that residents were assessed and supported appropriately for feeding assistance, that meal intake was documented as care planned, or that decreased intake was reported to licensed staff for further evaluation.