Failure to Provide Adaptive Equipment During Meals
Penalty
Summary
The facility failed to provide necessary adaptive equipment for two residents who required it during meals. Resident 6, who has diagnoses including dysphagia and hemiparesis affecting the right dominant side, was identified as being at risk for nutritional problems. The care plan and a physician's order specified that Resident 6 should receive beverages in handled mugs with lids. However, during a lunch meal observation, it was noted that while Resident 6 was served beverages in handled mugs, the lids were not in place, contrary to the prescribed intervention. Similarly, Resident 24, who has diagnoses including dementia, Parkinson's disease, and muscle weakness, was also identified as being at risk for nutritional problems. The care plan and a physician's order directed that Resident 24 should be provided with a handled mug with a lid during meals. During the same lunch meal observation, it was observed that Resident 24 was served beverages in a handled mug without the lid in place. This oversight indicates a failure to adhere to the prescribed interventions for both residents, potentially impacting their nutritional intake and safety.
Plan Of Correction
Director of Nursing completed an audit of residents with adaptive equipment for meals to ensure ordered equipment is in place. Nursing and Dietary staff will be re-inserviced by Director of Nursing/Designee on ensuring ordered adaptive equipment is in place at mealtime. Random audits will be completed by Director of Nursing / Designee on ensuring residents have their adaptive equipment during meals weekly x4, monthly x2. Results of audits will be reviewed by the facility QAA Committee for further recommendations and/or follow-up.