Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide adaptive eating equipment for a resident, identified as R83, who was observed during dining on the third-floor dining room. The facility's policy titled "Assistive Devices and Equipment" states that they maintain and supervise the use of assistive devices and equipment for residents, including specialized eating utensils. Recommendations for the use of such devices are based on comprehensive assessments and documented in the resident's care plan. However, during an observation of lunch, Resident R83, who had an order for buildup utensils, was given regular utensils instead. Resident R83 has a medical history that includes malnutrition, hemiplegia, aphasia, and stroke, and has been assessed with severe cognitive impairment. A physician's order dated January 4, 2024, specified the use of buildup utensils with meals. An interview with the resident's family confirmed that the resident was supposed to have special utensils but did not receive them. A nurse aide, identified as Employee E8, also confirmed that the resident was supposed to be given buildup utensils but did not receive them during the meal observed.
Plan Of Correction
1) Resident R83 was immediately provided with their assistive devices. 2) Current residents who are ordered assistive devices with meals have been audited to ensure assistive devices are available for use. 3) Dietary director / designee will educate dietary staff on ensuring assistive devices are provided to any resident indicated for such. 4) Dietary director / designee will complete random audits to ensure identified residents are provided with ordered assistive devices. Audits will be completed weekly x 3, monthly x 2, or until compliance is met. Variances will be addressed and reported to the QAA Committee.