Failure to Provide Dignified Meal Service and Assistance
Penalty
Summary
The facility failed to provide meals in a dignified and homelike manner, as observed in the main dining room and resident units. On multiple occasions, staff placed meal trays in front of residents without removing food items from the trays and used the tray lids as garbage receptacles, leaving trash in front of the residents. This practice was confirmed by the Registered Dietitian and the Food Service Director, who acknowledged that it was not dignified and that carts should be used for dirty items. Additionally, the facility failed to provide meal assistance in a dignified manner. A CNA was observed using a cell phone while assisting a resident with their meal, neglecting hand hygiene, which is crucial for infection control. Another staff member was observed feeding a resident while standing, contrary to the facility's policy that requires staff to be seated for safety reasons. These actions were acknowledged by the staff and the Director of Nursing as inappropriate and not in line with the facility's standards for resident care.
Plan Of Correction
Rose Mountain Care Center Facility ID 315384 Survey Date 12/12/24 F550 SS E **ELEMENT ONE: CORRECTIVE ACTION** All staff that pass out food trays were re-inserviced on 12/3/24-12/5/24 on hand hygiene for both residents and staff pre, post meal and when passing out trays. In addition, staff were re-inserviced on not leaving garbage including cup lids. C.N.A. #2 was immediately re-inserviced and counseled on zero tolerance on phone use as per facility policy, and in employee handbook, educated upon hire, annually, and as evidenced by C.N.A. signature in employee handbook. In addition, C.N.A. #2 was re-inserviced on sitting level with resident while assisting with meals. **ELEMENT TWO: IDENTIFICATION OF AT RISK RESIDENTS:** All residents that require hand hygiene prior to meals and require assistance with meals can be affected. All residents can be affected by staff personal cell phone use. **ELEMENT THREE: SYSTEMIC CHANGES:** All staff that pass out food trays were re-inserviced on 12/3/24-12/5/24 on hand hygiene for both residents and staff pre, post meal and when passing out trays. All staff were re-inserviced on zero tolerance on personal use of cell phones. All staff that assist residents with eating were re-inserviced on sitting level with resident while assisting with meals. A visual audit of meal pass was completed daily x 5 days starting 12/5/2024 at various mealtimes to assess any staff members that may not be practicing proper hand washing with residents and when passing out trays, as well as when assisting residents to eat, staff is sitting. The Director of Nursing/Licensed Nursing Home Administrator completed daily facility rounds at different times to audit staff personal cell phone use. **ELEMENT FOUR: QUALITY ASSURANCE:** Food Service Director/Dietician/Designee will visually audit (and document) dining services at various times/meals to assess staff compliance with resident and staff hand hygiene, and staff are sitting when assisting resident with meals, daily x 5 days, weekly x 4 and monthly x 4. Needed corrections will be addressed as they are discovered. Findings to be reported to QAPI team for review and action as necessary. DATE OF COMPLIANCE: 12/25/24