Failure to Provide Proper Adaptive Eating Equipment and Assistance
Penalty
Summary
The facility failed to provide appropriate special eating equipment and assistance for a resident with significant physical and cognitive impairments. The resident, who had spastic hemiplegic cerebral palsy, severe intellectual disabilities, and general weakness, required the use of a plate guard to assist with eating. Despite documentation in various assessments and care plans indicating the need for a plate guard, there were no specific instructions regarding the correct positioning of the plate guard, how it should be used, or who was responsible for ensuring it was properly placed during meals. Observations revealed that the plate guard was inconsistently positioned on the resident's plate during meals, resulting in food spillage onto the table and the resident's clothing. Staff did not provide assistance or cueing while the resident ate, and the plate guard was not always placed in a manner that would prevent food from falling off the plate. Interviews with staff, including nursing, dietary, and therapy personnel, confirmed a lack of clarity regarding the correct placement of the plate guard, the responsible party for its placement, and the absence of clear instructions in the care plan or other documentation. The care plan and nutritional assessments referenced the use of a plate guard but failed to specify the necessary details for its effective use. Staff interviews indicated that there was no policy or standardized process for the use of assistive devices during meals, and the care plan did not include information about the correct positioning of the plate guard or staff responsibilities. This lack of guidance and oversight led to inconsistent and inadequate support for the resident's eating needs.