Inadequate Provision of Assistive Dining Devices
Penalty
Summary
The facility failed to provide appropriate assistive dining devices for a resident, identified as Resident A11, who was diagnosed with dementia and dysphagia. The resident's physician had ordered a regular diet with dysphagia/advanced consistency, thin liquids, and the use of a spouted sip cup for all liquids, explicitly prohibiting the use of straws. However, during an observation, Resident A11 was found with a meal tray that included a straw and lacked the prescribed spouted sip cup. The resident's daughter confirmed that her mother had difficulty drinking at mealtimes and required a handled sippy cup, as per the physician's order, but was instead provided with a straw, which the resident could not use. Despite informing the facility administration, no corrective actions were taken. Further investigation revealed that the facility's inventory of adaptive dining equipment was insufficient to meet the needs of all residents requiring such devices. The facility had only one sippy cup available, while four residents required two-handled cups, six residents required Kennedy cups, and three residents required nosey cups. The corporate dietary manager confirmed the inadequacy of the adaptive dining equipment supply and acknowledged that the facility was responsible for obtaining the necessary equipment, despite outsourcing dietary services to an external vendor. The dietary manager was unable to provide information on how the dietary department ensured quality assurance for the availability of adaptive equipment.
Plan Of Correction
- A11-provided necessary devices when noted on 1/7/2025. - House audit completed on residents needing assistive devices on 1/7/2025. - House audit completed on par levels for adaptive equipment on 1/7/2025. - Re-education provided to all nursing staff and dietary staff on adaptive equipment and procedure if missing adaptive equipment noted. - The DON or designee will conduct weekly audit x 4, then monthly x 2 for adaptive equipment. - Audits will be presented at the monthly QAPI committee for ongoing oversight.