Failure to Properly Position Resident Before Meal Service
Summary
A deficiency occurred when a resident with mild cognitive impairment, muscle wasting, and a need for assistance with personal care and positioning was not properly positioned in the dining room prior to eating lunch. The resident was observed lying in a high-rise wheelchair with the head of the wheelchair at about a 45-degree angle. Despite the resident's request to be seated upright before receiving the meal tray, the activity aide served the lunch tray without adjusting the resident's position. As a result, the resident ate lunch while reclined, causing food to drop onto his chest area. The activity aide stated she did not reposition the resident because she was not a nurse and did not want to return the lunch tray, so she left the tray in front of the resident. The nurses later repositioned the resident, allowing him to finish his lunch. The Director of Nursing confirmed that the facility's expectation was for both activity and nursing staff to assist with resident positioning before serving meal trays.
Penalty
Resources
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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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