Failure to Maintain Resident Dignity and Offer Pleasure Foods
Penalty
Summary
A resident with a history of stroke, hemiplegia, dysphagia, chronic kidney disease, heart failure, and a PEG tube was repeatedly observed wearing a hospital gown during the day, with no documentation indicating this was the resident's preference. The resident was dependent on staff for dressing and personal hygiene and was not cognitively intact for daily decision making, according to the MDS assessment. Despite this, staff consistently dressed the resident in a hospital gown, and there was no care plan addressing this practice or indicating resident preference. Additionally, the resident was not consistently offered pleasure foods during meal times, even though there was no physician's order for nothing by mouth. Observations showed that while the resident's roommate received meal trays, the resident was not offered any food or pleasure items unless specifically requested. Interviews with staff confirmed that pleasure foods were only provided upon request, and the dietary manager stated that food was not routinely sent unless asked for. The DON acknowledged that pleasure foods should be offered at every meal, and there was no care plan supporting the use of a hospital gown during the day.