Failure to Provide Adaptive Eating Equipment for Resident with Hand Contractures
Penalty
Summary
The facility failed to provide adaptive eating equipment as recommended for a resident with bilateral hand contractures. Despite occupational therapy (OT) recommendations for built-up handles on utensils and handled cups to maximize the resident's independence during meals, the resident was observed using standard disposable plastic utensils and cups without adaptations. The care plan indicated the need to follow OT recommendations, but during multiple meal observations, the resident struggled to grip and use the provided utensils and cups, resulting in difficulty eating and drinking independently. Interviews with staff revealed that the foam handles previously used did not fit the plastic utensils currently in use due to ongoing kitchen repairs, and this issue was not communicated to management. The OT had educated at least one CNA about the adaptive equipment but did not ensure the recommendations were documented or communicated to the kitchen for implementation. There was also a lack of clear documentation and follow-through on the OT discharge recommendations, leading to the resident not receiving the necessary adaptive equipment during meals.