Dignity Violation: Inappropriate Beverage Service and Terminology
Penalty
Summary
The facility failed to maintain residents' dignity by serving milk and water in plastic storage cups with lids across four units. Observations during the survey period revealed that residents were consistently served beverages in these cups, despite their preference for hard plastic drinking cups. During a Resident Council Meeting, all ten residents expressed their dissatisfaction with the storage cups, preferring the hard plastic ones. The Food Service Director admitted to using storage cups due to portioning needs and was unaware that this practice was inappropriate. The facility had a limited number of hard plastic cups, which were primarily stored in the main dining room, and there was a delay in receiving new orders of these cups. The Director of Rehabilitation also noted the difficulty residents faced using the storage cups and had discussed this issue with the Director of Nursing. Additionally, a Certified Nurse Assistant (CNA) referred to a resident with severe cognitive impairment and dependency on eating assistance as a "feeder" during an interview. This terminology was also found in the resident's progress notes. The CNA acknowledged the inappropriateness of the term after the interview and had previously received in-service training on dignity. The Director of Nursing confirmed that the term "feeder" is unacceptable in the facility and should not be used in verbal communication or clinical documentation.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 F550 Ss=D The Plan of Correction is submitted in compliance with applicable law and regulation. To demonstrate continuing compliance with applicable law, the center has taken or will take actions set forth in following alleged deficiency. How corrective actions will be accomplished for residents found to have been affected by deficient practice: 1. The residents observed drinking out of plastic cups on unit 4 of 4. Facility immediately removed plastic storage cups for drinking use from 4 of 4 units. Supply order of tumbler cups for all units. Residents updated on tumbler cup order through resident council and are pleased with solution - all residents will be provided with tumbler cup for each meal. Measures put in place or systemic changes made to ensure that the deficient practice will not reoccur: - The director of dietary/designee will audit to ensure that plastic drinking cups will no longer be used for drinking. - Tumbler cups have been purchased for all residents. - A small emergency supply of additional tumbler cups was ordered to ensure they are always available. How facility plans to monitor performance to make sure the solutions are sustained: To ascertain the effectiveness of the education and audit was developed - The Director of dietary/Designee will audit 2 random meals per day to ensure tumblers are provided to nursing staff for each meal 5 x per week x 1 month, then weekly for 3 months. Any discrepancies will be reported to administrator and immediately corrected. The results of the Audit will be reported at monthly QAPI. 2. Certified nursing aide #7, the nursing staff and social worker on unit where resident #26 resides received education on resident rights and dignity specifically on the term “feeder” as being unacceptable and the correct language for residents who require assistance for feeding, Date 2/25/25. Resident care plan adjusted to reflect current levels of assistance required updated on 2/24/25. All residents have the potential to be affected by this practice - All residents requiring assistance with feeding during meals were observed during weeks 2/25/25 to 2/28/25 for use of improper terminology when assisting a resident with feeding, no occurrences found. Measures put in place or systemic changes made to ensure that the deficient practice will not reoccur: - The Policy titled Resident Rights was reviewed by Director of Nursing and Administrator on 2/24/25, with no revisions needed. - The director of nursing/designee will educate all nursing staff on assisting residents with meals with dignity and ensuring the correct terminology is used to identify the level of assistance the resident requires. How facility plans to monitor performance to make sure the solutions are sustained: To ascertain the effectiveness of the education and audit was developed. The DIRECTOR OF NURSING/DESIGNEE will audit progress notes of 5 residents who need assistance with meals weekly x 1 month, then monthly x 3 months to ensure proper terminology is used. The Director of Nursing/Designee will perform an Audit for Dining Room Observation during meal time to observe for appropriate terminology during meals. Random meal times during random days will be observed for 5 meals per week for 3 months. Any discrepancies will be immediately corrected and staff re-educated and/or counseled as needed. The results of the Audit will be reported at monthly QAPI.