Failure to Provide Adaptive Feeding Devices
Penalty
Summary
The facility failed to provide adaptive feeding devices for a resident, identified as Resident 53, who required them. According to the facility's policy on 'Assistance with Meals,' adaptive devices such as silverware with enlarged handles, plate guards, and specialized cups should be provided to residents in need. Resident 53's clinical record indicated a need for a lip plate and a Kennedy cup with meals, as per active physician orders dated September 10, 2024. The resident's care plan, revised on November 3, 2023, also specified the use of these devices. Observations conducted on December 2, 3, and 4, 2024, revealed that while Resident 53 was provided with a lipped plate during lunch, the Kennedy cup was consistently missing. This oversight was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the resident should have been served with a Kennedy cup. The deficiency was noted under the regulatory code 28 Pa code 211.6(a) - Dietary Services.
Plan Of Correction
1. Resident 53 had no adverse effect from not receiving kennedy cup with noon meal. 2. An initial audit of resident who use kennedy cups was completed to ensure that it was received as ordered. 3. Education was completed with dietary and nursing staff on ensuring that kennedy cups are provided as ordered. 4. 5 audits of residents who require kennedy cups will be conducted weekly x 4, then monthly x 2 by NHA or designee. Results of this audit will be presented to the QAA committee for review. 5. The facility will be in substantial compliance by 1/7/25.