Failure to Provide Adaptive Dining Equipment
Penalty
Summary
The facility failed to provide the necessary adaptive dining equipment for a resident, identified as Resident 46, who required specific utensils due to medical conditions. Resident 46 was admitted with early onset Alzheimer's disease and cerebrovascular disease, and had a care plan indicating a need for a maroon pediatric spoon to aid in safe swallowing due to dysphagia. Despite the physician's orders, the resident was observed being fed with a white plastic spoon instead of the prescribed maroon spoon on multiple occasions. Observations on two separate days revealed that the staff did not use the required maroon spoon during meal times, and interviews with staff confirmed the absence of the correct utensil. The Director of Rehab acknowledged the facility's failure to provide the adaptive equipment as ordered, which increased the risk of choking and compromised the resident's safety.
Plan Of Correction
The facility cannot retroactively correct the deficiency noted by the surveyor for resident 23. The facility recognizes that all residents with orders for adaptive equipment have the potential to be affected. The Registered Dietitian or designee will audit residents with orders for adaptive equipment to verify the equipment is being utilized as ordered. The Registered Dietitian (RD) or designee will re-educate the dietary and nursing staff on utilizing adaptive equipment as ordered for meals. The RD or designee will conduct weekly audits for 4 weeks and then monthly for 2 months to verify adaptive equipment is being utilized as ordered for meals. Audits will be submitted to the monthly QA committee meeting for review and any further recommendations for 3 months. F 0810