Failure to Provide Adaptive Feeding Devices
Penalty
Summary
The facility failed to provide adaptive feeding devices for a resident, identified as Resident R42, who required them. Resident R42 was admitted to the facility on August 1, 2023, and had diagnoses including high blood pressure, dementia, and Parkinson's disease. The resident's care plan, dated January 20, 2025, specified the use of a two-handled sippy cup with a spout for meals. However, during an observation on January 22, 2025, at lunchtime, it was noted that Resident R42 was not provided with the prescribed spouted cup, but instead was given a regular cup. This was confirmed by the Dietary Director and the Director of Nursing, who acknowledged the facility's failure to provide the necessary adaptive feeding device for the resident.
Plan Of Correction
There were no negative outcomes as a result of missing adaptive utensils and sippy cup lid. Dietary staff will be educated by the dietary manager on adaptive equipment and the F810 tag. Audits will be done daily for 2 weeks by dietary supervisor, and bimonthly for two months. All results to be reviewed through QAPI for further recommendation. On 2/25/25, the dietary manager educated all dietary staff on each type of resident adaptive equipment and the importance of ensuring all adaptive equipment is present on each resident tray for every meal as ordered. Audits will be performed by the dietary supervisor, checking that each resident's specific adaptive equipment is listed on the tray ticket and that the item is visible on the resident tray. The audit will be performed daily for 2 weeks, then monthly for two months. All results will be reviewed through QAPI for further recommendations.