Failure to Provide Assistive Eating Devices as Per Care Plan
Penalty
Summary
The facility failed to provide assistive devices for eating in accordance with the care plan for one resident. The resident, who was severely cognitively impaired, was assessed to be independent with eating after setup and required her food to be served in bowls, one at a time, as per her care plan and speech therapy notes. However, during an observation of the lunch meal, the resident was served pork, mashed potatoes, and sauerkraut on a plate instead of in separate bowls. This was confirmed by the Nursing Home Administrator, who acknowledged that the resident's food should have been served in separate bowls, one at a time, as care planned.
Plan Of Correction
1. Resident 1 experienced no ill-effects from this deficient practice. 2. An audit was completed by the Director of Dining Services, or designee, to ensure that current residents requiring adaptive feeding devices had their care-planned assistive feeding devices in place before the residents began eating their meal. 3. An education was completed with all nursing staff and dining services staff members on the policy for adaptive feeding devices and ensuring that residents receive their care-planned assistive feeding devices before the residents begin eating their meal. 4. An audit will be conducted on 5 currently active residents requiring adaptive feeding devices to ensure that they have their care-planned assistive feeding devices in place before the residents begin eating their meal weekly x 4 weeks, then monthly x 2 months. The results of these audits will be forwarded to the Quality Assurance Performance Improvement (QAPI) committee for review.