Inappropriate Use of Feeding Assistants for Residents with Complicated Eating Problems
Summary
The facility failed to ensure that residents with complicated eating problems were not assisted by paid feeding assistants, as observed in the cases of five residents who were on pureed diets. These residents, identified as having issues such as pocketing food, dysphagia, and other swallowing difficulties, were assisted by individuals who were not certified nursing assistants (CNAs) but rather paid feeding assistants. The facility's policy and training materials explicitly stated that feeding assistants are not permitted to assist residents with complicated eating or drinking problems, including those with dysphagia. Observations and interviews revealed that cosmetologist AA, who was trained as a paid feeding assistant but not a CNA, assisted resident 19 with eating despite the resident's recent weight loss, pureed diet, and hospice care status. Similarly, activities aide Y, also a paid feeding assistant, assisted resident 41 with eating. The staff development coordinator, who was new to the role, was unsure if the training covered residents with special diets, and the speech therapist did not consider issues like pocketing food or the need for altered food textures as complicated feeding issues. The facility's records and interviews indicated a lack of documentation in the care plans of residents 6, 7, 15, 19, and 41 regarding their participation in the feeding assistant program. The interdisciplinary team, based on the speech therapist's recommendations, determined resident participation in the program, but the care plans did not reflect this. The facility's policy required that feeding assistants only assist residents without complicated eating problems, yet the feeding assistant list did not exclude any residents, and care plans did not specify which residents required CNA assistance.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Surveyors found that non‑nursing staff, including the Administrator and a Medical Records clerk, were assisting multiple dependent residents with eating without documented completion of a State‑approved feeding assistant training course. Observations showed residents with bilateral upper extremity weakness, contractures, inability to lift their arms, and reliance on verbal prompts to open their mouths being fed by these staff. Interviews with HR, the ADON, the ADMIN, and the RNC revealed confusion about where feeding assistance training was housed, missing or unavailable training records, and in‑service sheets that did not include the ADMIN or MR clerk as attendees. Record review from hire to current date confirmed no documented feeding assistant training for these staff, and the ADMIN reported the facility had no policy on feeding assistant training, despite regulatory requirements. The report states this failure could place residents who require assistance with eating at risk of aspiration and choking.
A resident with dysphagia, a mechanically altered diet, and documented coughing during meals was allowed to be fed by PNAs even though the care plan and swallow study identified aspiration concerns and safe-swallow precautions. Staff interviews showed PNAs assisted the resident routinely, one PNA reported coughing after every drink, and the DON stated the facility did not have residents PNAs could not assist, despite policy limiting residents with recurrent aspiration or difficulty swallowing to licensed or certified staff.
Staff failed to follow facility policy for assisting with in-room meals for three cognitively impaired residents who required varying levels of help with eating. One resident with metabolic encephalopathy, dementia, and total dependence for eating was found lying flat in bed with food in the mouth and on the linens while the meal tray remained mostly untouched and covered; the assigned CNA had been redirected to the dining room to assist two other residents needing feeding help and did not promptly return. For all three residents, care plans required documentation of PO intake at every meal, but intake records for the cited day showed either no intake data or "resident not available," and the CNA did not report decreased intake to an LVN as expected. Interviews revealed that usual restorative nursing assistant coverage in the dining room was absent that day, CNAs were managing multiple feeder residents, and charge nurse supervision did not ensure that feeding assistance and intake documentation were completed according to policy.
The facility did not ensure that residents receiving paid feeding assistance were properly assessed for program appropriateness, nor did it verify that staff providing this assistance had completed required training. A resident with swallowing difficulties received feeding assistance without documented assessment, and another was assisted by a staff member unable to provide proof of training. Facility policy required both assessments and verified training, but these were not documented or completed.
A resident with severe cognitive impairment and special dietary needs was fed by a Unit Assistant who had not completed the required State-approved feeding assistant training. Facility staff and leadership confirmed that Unit Assistants received only in-house training and were unaware of the need for State-approved certification, resulting in the resident being assisted by unqualified personnel.
A resident with dysphagia and partial paralysis had a physician order for 1:1 supervision and assistance during meals, including cues to slow eating and pre-cut food. Staff were observed leaving the resident unattended during meals, and there was no documentation of required supervision for the past month. Facility policies required following physician orders and providing meal assistance based on individual needs, but these were not followed.
Untrained Non‑Nursing Staff Providing Feeding Assistance Without Required Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff who were assisting residents with eating had successfully completed a State‑approved feeding assistant training course before providing this care. Over a three‑day observation period, surveyors observed the Medical Records (MR) clerk and the Administrator (ADMIN), both non‑nursing staff, feeding three unknown residents in the dining room who required full feeding assistance. One resident had bilateral upper extremity weakness and contractures, another sat upright in a specialized chair and did not attempt to lift either upper extremity, and another sat slightly hunched over and was not trying to lift their upper extremities. A further resident only opened their mouth for the ADMIN when verbally prompted. In each instance, CNA D confirmed that these residents needed feeding assistance. The report states that this failure could place residents who require assistance with eating at risk of aspiration and choking. During interviews and record reviews, the facility was unable to produce documentation that the ADMIN and MR clerk had completed a State‑approved feeding assistant training course. The HR representative stated that feeding assistance training was not part of the new hire packet, that some trainings were done as in‑services or department‑specific, and that paper copies could not be located, partly due to a change in company systems. HR later provided pre‑acquisition training paperwork that did not include feeding assistance training and acknowledged that the training for feeding assistance might not auto‑populate in the new system. The ADON believed feeding assistance training was included in dementia training and said it might be in Relias or in the DON’s office, but no documentation was produced. The ADMIN confirmed she could not locate training records and the in‑service sheets she provided did not list her or the MR clerk as attendees. The RNC verbally verified that the ADMIN and MR clerk had been present for training but had no signed documentation. Record review from hire to current date for the ADMIN and MR clerk showed no completed feeding assistance training, and an in‑service sheet for feeding assistance lacked their signatures. The ADMIN also stated the facility did not have a policy on training for feeding assistance, despite regulatory requirements that non‑nursing staff must complete a State‑approved course before assisting residents with feeding.
PNA Assisted Resident With Dysphagia and Coughing During Meals
Penalty
Summary
The facility failed to ensure that a resident with dysphagia and a high risk for aspiration was fed only by licensed or certified staff. Resident #20’s MDS identified a mechanically altered diet, and the care plan directed assistance with eating and monitoring for signs and symptoms of aspiration or difficulty swallowing. A video swallow study documented coughing during meals, a diagnosis of dysphagia, and recommendations for pureed food with mildly thick liquids and strict safe swallow precautions, including small bites and sips and a slow rate of intake. Despite these findings, the PNA-Resident Dining assessment determined that Resident #20 could eat with the assistance of a PNA. Staff interviews showed PNAs assisted the resident with meals on a regular basis, and one PNA reported the resident coughed after every drink and that she did not report the coughing to the nurse. The DON stated the facility did not have residents that PNAs could not assist, and later stated a PNA may assist if Speech Therapy approved, while also expecting the PNA to get a nurse if the resident started choking or coughing. The facility policy stated residents with recurrent lung aspiration or difficulty swallowing are to be fed only by nurses, nurse aides, or other licensed health professionals.
Failure to Provide and Document Required Feeding Assistance and Intake Monitoring
Penalty
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.
Failure to Assess Residents and Verify Staff Training in Paid Feeding Assistance Program
Penalty
Summary
The facility failed to ensure that residents receiving paid feeding assistance were properly assessed for appropriateness and that staff providing this assistance were adequately trained. One resident required one-person total assistance with eating and was observed being assisted by a recreation therapist, who claimed to have received paid feeding assistant training. However, the staff member was unable to provide a valid training certificate, and the facility could not locate documentation confirming completion of the required training. Another resident, who had documented swallowing difficulties and required thickened liquids, was also receiving paid feeding assistance. Review of the resident's records showed no documentation of an assessment to determine if they were appropriate for the paid feeding assistance program, despite facility policy requiring such an assessment for residents with complicated feeding problems, including swallowing difficulties. Interviews with facility staff revealed a lack of awareness regarding responsibility for completing these assessments, and the Director of Nursing confirmed that the resident did not meet the criteria for the program and that no assessment documentation existed. Facility policy stated that only residents without complicated feeding problems should be considered for the paid feeding assistant program and that only appropriately trained staff should provide this assistance. The lack of assessment and training documentation for both residents and staff led to the deficiency, as residents with special dietary needs and risks were assisted by staff whose qualifications could not be verified.
Unqualified Staff Fed Resident Without State-Approved Training
Penalty
Summary
A deficiency was identified when a resident with Alzheimer's disease, dementia, and abnormal weight loss, who was dependent on staff for all activities of daily living including eating, was fed by a Unit Assistant who had not completed a State-approved feeding assistant training course. The resident required a mechanically altered diet with aspiration precautions, and the care plan specified that staff should feed and assist the resident to complete meals. During observation, the Unit Assistant was seen feeding the resident puree food, and both the Unit Assistant and facility leadership confirmed that the assistant had only received in-house training and was unaware of the requirement for State-approved training. Interviews with the Director of Human Resources and the Director of Nursing revealed that Unit Assistants routinely feed residents after receiving facility-based training, but none had completed the required State-approved eight-hour course. Documentation supporting completion of State-approved training for feeding assistants was not available, and facility leadership was not aware of the regulatory requirement for such training. This resulted in the resident being fed by unqualified staff, contrary to regulatory requirements.
Failure to Provide Required Supervision and Assistance During Meals
Penalty
Summary
A resident with diagnoses including dysphagia and partial paralysis to the left side was admitted to the facility and had a physician order for 1:1 supervision during meals, cues to slow eating, and pre-cut food into bite-sized pieces. Observations revealed that the resident was left unattended during meal times, with staff delivering meal trays, positioning the resident, and then leaving. On two separate occasions, the resident was found alone with her meal tray, without the required supervision or assistance. A review of the resident's electronic record showed no documentation of 1:1 supervision for meals over the past 30 days, despite the physician's order. When requested, the facility was unable to provide a policy and procedure defining levels of meal assistance. The facility's existing policies indicated that residents should receive meal assistance according to their individual needs and that physician orders should be followed as prescribed. The nurse practitioner confirmed that staff are expected to follow orders for resident safety.
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