Failure to Provide Adaptive Drinking Equipment for Resident with Physician Orders
Penalty
Summary
The facility failed to provide required adaptive equipment for a resident with physician orders specifying the use of a scoop dish and a two-handled cup with lid to maximize intake and minimize spillage. Observations revealed that the resident, who had diagnoses including Non-ST Elevation Myocardial Infarction and required assistance with personal care, did not consistently receive the adaptive drinking equipment for each beverage. Specifically, the resident was observed with a Styrofoam cup of water on the overbed table without the prescribed two-handled cup, and at another time, only one two-handled cup was present for multiple beverages on the breakfast tray. Interviews with staff indicated that the process for providing adaptive equipment was inconsistent. A CNA reported that she would rotate the two-handled cup between different beverages, rinsing and refilling it as needed, and would obtain a clean cup for water only after breakfast. The Dietary Manager stated that a two-handled cup should be provided for each beverage, but also noted that nursing staff were responsible for obtaining and returning the cups for cleaning. These actions and inactions resulted in the resident not having the necessary adaptive equipment for all drinks as required by their care plan and physician orders.
Plan Of Correction
On the meal tracker tray cards for resident #19 were updated to include two handled cups for each beverage provided. On the CDM conducted a quality review of current residents who require adaptive equipment to ensure that the Meal Tracker Tray Card contains the appropriate adaptive equipment with no additional findings noted. On the Regional Director of Environmental and Food Services educated the Certified Dietary Manager on the components of F810 with an emphasis providing appropriate quantity of adaptive equipment on the meal tray. On the Certified Dietary Manager educated the dietary staff on the components of F810 with an emphasis on providing appropriate quantity of adaptive equipment on the meal tray. As part of a systematic change, newly hired dietary employees will be educated on the components of F810 with an emphasis on providing appropriate quantity of adaptive equipment on the meal tray during orientation. The administrator/designee will conduct 5 observations weekly x 4 weeks, then 10 observations monthly x 2 months to ensure that appropriate adaptive equipment is on the meal tray. The findings of these quality monitoring to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.