Failure to Implement Care Plan for One-on-One Feeding Assistance
Penalty
Summary
A deficiency was identified when the facility failed to implement a care plan for a resident with significant Activities of Daily Living (ADL) needs. The resident had a care plan in place for ADL self-care performance deficit related to dementia, hemiplegia, limited range of motion, and a history of stroke, which included an intervention for one-on-one feeding assistance. Despite this, observations and interviews revealed that staff did not consistently provide the required one-on-one assistance during meals. Instead, a collateral contact (family member or representative) was often present and ended up assisting the resident with meals because staff would leave the meal tray and not return promptly to provide the necessary support. Staff interviews confirmed that they were expected to follow the care plan and remain with the resident for the entirety of the meal when one-on-one assistance was required. The Director of Nursing also stated that staff were responsible for assisting residents with meals and that any involvement of a resident representative in feeding should be documented in the care plan. The failure to implement the care plan as written resulted in the resident not consistently receiving the required assistance with eating.