Failure to Provide Assistive Eating Devices
Penalty
Summary
The facility failed to provide assistive devices as ordered by the physician for a resident, identified as Resident 23, who was moderately cognitively impaired and required set-up assistance with eating. The resident had a physician's order to use a divided plate to facilitate easier access to food, as indicated in the resident's meal ticket for the noon meal. However, during an observation on April 15, 2025, at 12:02 p.m., it was noted that the resident did not have the divided plate while eating in the dining room. This was confirmed by an interview with a Licensed Practical Nurse at the time of the observation.
Plan Of Correction
Licensed Practical Nurse on the unit immediately provided Resident 23 with fresh food and appropriate divided plate. Immediately after meal services, the Dietary Aid, which was responsible for providing the plate, was re-educated on the order for residents' adaptive equipment and noted that it was present on the meal ticket to ensure compliance. The Adaptive Equipment Policy was reviewed with no change needed. It will be educated and reviewed with all current staff which assist with meal service. Acknowledgements will be obtained and documented. All newly hired staff as well as temporary (agency) staff and Hospices which assist with meals are to be educated, as necessary. An audit/review was completed for all Adaptive equipment ordered for residents with a visual analysis on the equipment being noted on residents' meal tickets as well as successful execution on providing appropriate equipment to the residents. Dietary Management or Designee will inspect the use of adaptive equipment at meal service. Audits to ensure compliance will occur at the following Schedule: Initially, one meal per day x 7 days for two weeks, followed by one meal per day x 3 days for two weeks and finally one meal a day x 1 day for one week and/or as needed. On-the-spot education will be provided to staff as needed. The results of these logs/audits along with a Root Cause Analysis of any identified issues will be brought to the Quality Assurance and Performance Improvement Committee for two quarters for further analysis and corrective action as needed. The committee will determine the need for additional audits or reporting.