Failure to Assist Residents During Dining
Penalty
Summary
The facility failed to provide necessary assistance during dining for two residents, specifically Resident #71 and Resident #52, who were reviewed for activities of daily living (ADLs). Resident #71 was admitted with diagnoses including Atherosclerotic Heart Disease and Neuromuscular Dysfunction of the Bladder. The Minimum Data Set (MDS) assessment indicated that Resident #71 had a moderately impaired mental status and required supervision or touching assistance during dining. However, observations on two separate occasions revealed that Resident #71 was left unattended with her meal trays for extended periods, without any staff present to assist or encourage her to eat. Interviews with facility staff revealed inconsistencies in understanding the level of assistance required by Resident #71. A Certified Nurse Assistant (CNA) acknowledged that the resident sometimes needed to be fed and encouraged to eat, while a Registered Nurse (RN) believed the resident could eat without staff presence. The MDS Coordinators clarified that supervision or touching assistance meant the resident needed help with tray setup and encouragement during meals. Despite this, the CNAs, who were responsible for dining assistance, were not consistently present to provide the necessary support, leading to the deficiency in care.
Plan Of Correction
The facility failed to provide assistance during dining. **Actions Taken:** 1) Resident #71 remains in the facility in stable condition. A screen was conducted on [date]. The resident now attends the dining room for her meals for oversight and assistance as needed. Staff E, CNA and staff F, RN were re-educated to refer to resident Kardex in reference to the amount of assistance required with meals on [date] by Aristine Recht, Assistant Director of Nursing. **Others Identified:** 2) A full house audit was conducted by the Director of Nursing/Designee on [date] to ensure residents were provided assistance during dining. Any concerns identified were immediately addressed. **Measures Taken:** 3) Nursing staff were re-educated on providing assistance to residents during dining as per resident Kardex on [date] by DON/Designee. Newly hired nursing staff will receive this education during general orientation. **Ongoing Monitoring:** 4) The Director of Nursing/Designee will conduct an audit of 10 residents on each unit weekly to ensure the residents receive assistance during dining weekly for 4 weeks, and then every 2 weeks for 2 months. Findings of the audits will be reviewed in the QAPI Meetings to ensure substantial compliance. The QAPI committee is responsible for the ongoing compliance.