Dignity Issue Due to Delayed Meal Delivery
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity during meal times, as observed during a recertification survey. On the [NAME] Unit, a secure dementia unit, residents were seated at tables waiting for their lunch trays, but due to delays in the delivery of meal transport racks from the kitchen, some residents received their meals while others at the same table did not. This resulted in a situation where some residents were eating while others were left waiting, which was identified as a dignity issue. The facility's policy on resident rights emphasizes the importance of dignity and respect, yet the meal delivery system did not align with these principles. Interviews with staff, including LPNs and CNAs, revealed that the late arrival of meal transport racks was a known issue, and the kitchen staff was aware of the problem. The General Manager for kitchen and dining operations acknowledged the need for better coordination between nursing, kitchen, and dietary staff to ensure that all residents at a table are served simultaneously. The Director of Nursing Services also emphasized that even though residents on the dementia unit may be confused, they should still be able to eat together rather than watching others eat, highlighting the importance of maintaining dignity during meal times.
Plan Of Correction
Plan of Correction: Approved January 6, 2025 I. The following actions were accomplished for the residents identified in the sample: No specific residents were identified in the Statement of Deficiencies. On 12/30/24, a seating chart was developed by the Nurse Manager for the Kipp unit and provided to the Dietary Department, so that truck order of trays is consistent with seating chart and all residents at the same table receive their meal at the same time. On 12/4/24 the Staff Educator/designee provided Inservice training to the Kipp unit Nursing staff on meal service, including serving all residents seated at the same table their meal tray at the same time. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents have been identified as potentially being affected by same practice. Effective 12/30/24, education was provided to Nursing and Dietary staff related to the facility policy and procedure for the development of seating chart for all units for mealtimes, and dietary developing a system to arrange food trucks in table order so that all meal trays for residents at the same table arrive on the units at the same time by Food Supervisor. This education included staff discussion regarding importance of resident respect, dignity and quality of life as it relates to mealtimes, including concerns for residents at the same table receiving trays at the same time. This education also included the need to review and update seating charts on a routine basis and Nursing’s responsibility for alerting the Dietary Department of any changes needed to the truck tray order. Nurse Managers and Dietitians will conduct meal observations on a random basis for all meals and shifts weekly to identify any concerns related to meals not being served in table order. Issues identified with the food carts not being loaded in table order for distribution will be addressed by the Food Service Director for all reported concerns. Issues related to a resident being seated at a table that is inconsistent with the seating chart will be addressed by the Unit Nurse Manager. The Manager will update the seating chart, if indicated, or provide staff education regarding their responsibility to adhere to the seating chart during all meals. If a resident must be moved to another table for meals, the Manager will promptly update the seating chart. III. The following system changes will be implemented to assure continuing compliance with regulations: The Director of Food Service reviewed and revised, as needed, the Food Service policies and procedures related to preparation of meal trucks, including providing trucks in order of residents seating to ensure that all residents receive their meal at the same time at each table. The Chief Nursing Officer reviewed and revised, as needed, policies and procedures related to resident dining and meal service related to resident rights and quality of life and directed the development of resident seating charts for each unit, which will be updated, as needed, and be provided to dietary when updated. Effective 12/10/24, the Director of Food Service/Designee and Chief Nursing Officer/Nurse Managers/designee will monitor meals to ensure all residents at same table are provided with meals at same time daily for 4 weeks, weekly for 2 months, then quarterly. Corrective action, including Nursing of Food Service staff re-education, will be implemented as necessary. The Staff Educator/Director of Food Service/designee will provide additional education to all Nursing and Dietary staff whenever issues related to residents receiving meals at same time when seated at the same table are identified. The Director of Food Service will review meal service findings with the Administrator monthly for three months then quarterly. IV. The facility’s compliance will be monitored utilizing the following quality assurance system: The facility will develop an audit tool to monitor compliance with Resident Rights related to meal service including residents at same table receiving meals at same time, accuracy of seating charts and accuracy of meal tray order on trucks to ensure meal service promotes resident dignity and respect and quality of life. The Director of Food Service/Designee will conduct monitoring of residents at same table receiving meals at same time monthly for three months then quarterly for the next nine months. The Director of Food Service/Designee will conduct competency evaluations of all Food Service workers to assure they are following established protocols and have a clear understanding of the protocols for proper truck order. On-site education will be provided, as necessary, to ensure staff compliance. Competency evaluations will be conducted of all new Food Service Workers upon completion of orientation and twice yearly thereafter. Chief Nursing Officer/designee will conduct meal service observations of nursing staff job performance during meal service to ensure resident respect and dignity and quality of life concerns are addressed when identified. Observation will include assessing the development and currency of seating charts, communication of updates to the Dietary Department, and residents being in their designated seating area for meals. The Food Service Supervisor/designee will report residents’ meal service audit findings to the QAPI Committee monthly for the next 3 months then quarterly for the next 3 quarters. At the end of the fourth quarter, a decision will be made by the QAPI Committee regarding the need to continue auditing and at what frequency. Additional corrective action will be implemented as deemed necessary by the Committee. The Chief Nursing Officer will report meal service observation audit findings to the QAPI Committee monthly for the next 3 months then quarterly for the next 3 quarters. At the end of the fourth quarter, a decision will be made by the QAPI Committee regarding the need to continue auditing and at what frequency. Additional corrective action will be implemented as deemed necessary by the Committee. Completion Date: 01/31/2025 Responsibility: Director of Food Service