Dignity in Dining Experience Not Maintained
Penalty
Summary
The facility failed to ensure a dignified dining experience for two residents during the recertification survey. Resident #2, who was admitted with severe cognitive impairment and required extensive assistance for eating, was observed being fed by a Certified Nurse Aide (CNA) who stood over the resident while assisting with their meal. The CNA acknowledged awareness of the requirement to sit at eye level with residents during feeding but chose to stand for personal comfort. Similarly, Resident #113, who also had severe cognitive decline and was totally dependent on staff for eating, was observed being fed by another CNA who stood over the resident due to the unavailability of chairs. This CNA also acknowledged the requirement to sit at eye level with residents during feeding. A Licensed Professional Nurse confirmed that CNAs should always be at eye level with residents to maintain dignity during meals.
Plan Of Correction
Plan of Correction: Approved April 23, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Actions for Residents Identified Residents #2 and #13 Resident Rights The resident has a right to a dignified existence and respect. Residents #2 and #13 suffered no ill effects related to deficient practice. Residents will be provided with dignity and respect as evidenced by staff will be seated next to residents at eye level that require assist with meals. Resident Rights Following notification of this deficiency, resident #2 was assessed on 4/1/25 and found to have no [MEDICATION NAME] ill effects related to this deficient practice. Resident #13 was assessed on 4/1/25 and found to have no [MEDICATION NAME] ill effects as a result of this deficient practice. Aide #13 and Aide #5 were re-educated on 4/1/2025 on resident’s rights and the procedure for providing feeding assistance, the need to sit beside residents while providing assistance with feeding. Resident at Risk Any resident can be affected by this deficient practice. The Director of Nursing conducted an audit to identify any other resident who was affected by this deficient practice and none was identified. The facility respectfully states that while all residents had the potential to be affected by this deficiency, no other resident was found to be affected. The Administrator/Designee has conducted an audit of chairs within the facility, available for use by staff providing feeding assistance, and found that there are sufficient numbers of available chairs. Dependent residents can be affected by this deficient practice. Systemic Changes All nursing staff (CNA’s and Nurses) will be educated by Nurse Staff Educator/ADON/Designee on procedure with assisting residents with eating during meals. Specifically, staff should be seated next to resident at eye level while assisting with meal. The Administrator has reviewed the facility’s Policy on Quality of life-Dignity, and found it to be in compliance with all state and federal regulations. Education will be provided to all Nurses and CNAs on the procedure for providing feeding assistance, specifically, staff should be seated next to the resident and at eye level while assisting with meals. Monitoring for Corrective Action The DON has created a meal time audit to monitor for staff sitting while providing feeding assistance. Meal time audits will be conducted for lunch & dinner daily x 2 weeks, then weekly x 2 weeks, then monthly x 3 months. Audits will be presented at QAPI meetings monthly by the DNS to determine continued need. Review of Nursing staff attendance and completion of education will be monitored by Nurse Staff Educator/ADON/DNS. The DNS/Designee will be responsible for completion of this plan of correction. Responsible: The DNS/Designee will be responsible for completion of this plan of correction. Completion Date: 5/31/2025