Failure to Ensure Proper Positioning During Mealtimes
Summary
The facility failed to ensure proper functional positioning during mealtimes for a resident with chronic obstructive pulmonary disease, Parkinson's disease, and an above-knee amputation. The resident was observed eating in a wheelchair that was angled away from the dining table, forcing him to balance his plate on his abdomen. This positioning was due to the wheelchair being purposely dumped as a fall intervention, which caused discomfort and difficulty in eating and swallowing. The resident expressed discomfort and difficulty reaching the table, and no assistance was provided to help him cut his food into manageable pieces. Interviews with the Director of Rehabilitation and the Director of Nursing confirmed that the wheelchair's positioning was intended as a fall prevention measure, despite the resident's complaints of discomfort and difficulty in maintaining an upright posture. The Speech Language Pathologist also noted that the reclined position could increase the risk of aspiration. The facility's policy on resident rights emphasizes the importance of self-determination and freedom of choice, which was not upheld in this case as the resident's preferences and comfort were not adequately addressed.
Penalty
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The facility failed to properly position residents during meals, affecting three individuals on the secured unit. Observations showed residents in tilt wheelchairs at inappropriate angles and one resident in a low wheelchair without leg rests, unable to reach their meal. Staff did not intervene to reposition the residents, and interviews confirmed the improper positioning. The facility's policy on dignity and respect was not followed.
Improper Positioning of Residents During Meals
Penalty
Summary
The facility failed to ensure proper positioning of residents during meals on the secured unit, affecting three residents. Observations revealed that two residents were seated in specialty tilt wheelchairs at angles between 60 to 75 degrees, with one resident's table height reaching their chin throughout the meal. The staff did not intervene or reposition the residents during the meal observation. Another resident was observed sitting in a low wheelchair without leg rests, with their feet dangling, and was not positioned properly at the table during breakfast. Despite staff presence, no intervention was made to reposition the resident to allow proper access to their meal. Interviews with staff confirmed the improper positioning of residents during meals. One staff member acknowledged that a resident was not positioned correctly at the table, citing concerns about the resident grabbing items off the table. The Director of Nursing verified that residents should be upright and properly positioned at an appropriate table height during meals. The facility's policy on Quality of Life - Dignity emphasizes care that promotes dignity, respect, and individuality, which was not adhered to in these instances.
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