Failure to Ensure Dignified Dining Experience
Penalty
Summary
The facility failed to ensure a dignified dining experience for three residents during the recertification survey. Certified Nurse Assistants (CNAs) #17 and #21 referred to a resident as a 'feeder' during lunch service, which was acknowledged as inappropriate by the CNAs and the Director of Nursing. This incident occurred in the presence of other residents and staff, highlighting a lack of respect for the resident's dignity. Additionally, CNAs #36 and #37 were observed standing over two residents while feeding them, contrary to the facility's policy that requires staff to be seated when assisting residents with meals. The residents involved had various medical conditions, including dysphagia, cognitive impairments, and other chronic illnesses, necessitating assistance with eating. The care plans for these residents specified the need for respectful and appropriate assistance during meals, which was not adhered to by the staff. The Director of Nursing confirmed that staff should sit next to residents and engage in conversation during meals, which was not observed in these instances.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice? Residents were assessed and there were no signs of distress noted due to observed practice. 2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? An audit was completed by all unit nursing supervisors and/or designees to identify and create a list of all residents requiring assistance with eating. The facility will ensure that all residents in need of feeding assistance are not affected by this deficient practice by ensuring that all staff are educated on the rights of the residents and the responsibilities of the facility to properly care for all residents with dignity. The DON and/or designee will ensure that residents requiring assistance with eating are provided with the necessary assistance and staff communicates appropriately during the dining experience. This will be accomplished by conducting meal observations audits focused on residents requiring assistance at meal times. Audits will be reviewed to ensure that there has been no negative effects for residents requiring assistance with feeding i.e. weight loss, or resident intake is affected negatively. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur? The policy and procedure was reviewed and staff education provided on the policy Nursing, Feeding of Residents, and Resident Rights. All nursing staff including RNs, LPNs, and CNAs will receive in-service on the Residents Rights incorporating dignity, feeding and the dining experience, and the policy on Nursing Feeding of Residents with demonstration. This in-service will also be provided on an annual basis and new nursing employees at the time of hire. This in-service will also be provided to agency and contract staff. This training will be completed by the Nurse Educator and/or designee under the direction of the DON. Additional seating was provided for staff to ensure adequate seating in the dining room to assist residents with dining. 4. How will the corrective action be monitored to ensure the deficient practice will not recur? Each unit will be randomly audited 1 X per week by Nursing Supervisor or Designee to ensure residents have a dignified dining experience. All data will be submitted to the DON for analysis. Immediate problems observed during audits will be addressed and remediated to improve staff performance. The DON and/or designee will be responsible for ensuring that residents have a right to a dignified dining experience. The results of Audits will be reported to DON to be reported out at QAPI committee monthly X 3 months and quarterly thereafter for action as appropriate.