Failure to Provide Adaptive Equipment and Timely Interventions for Eating Independence
Penalty
Summary
The facility failed to implement timely interventions and provide adaptive equipment to maintain eating independence for a resident with mild cognitive deficits and physical limitations. The resident, who had a history of tremors and required setup assistance for eating, was observed repeatedly spilling food and struggling to eat independently during multiple meals. Despite an occupational therapy (OT) evaluation indicating the need to maximize independence with activities of daily living, there was no documentation of interventions or adaptive equipment being provided to address the resident's difficulties with eating. Observations revealed that the resident experienced significant food spillage, was unable to effectively use regular utensils and plates, and had difficulty keeping his wheelchair positioned at the table. Staff noted the resident's preference for independence but did not provide appropriate adaptive equipment or consistent assistance, resulting in the resident eating very little during meals and expressing continued hunger. The dietary manager confirmed that no adaptive feeding equipment was available in the facility, despite requests for such equipment for residents in need. Interviews with therapy and dietary staff indicated a lack of follow-through on orders for adaptive equipment and insufficient assessment of the resident's needs during mealtimes. The occupational therapy staff focused primarily on posture and trunk strengthening, overlooking the resident's functional challenges with self-feeding. Only after repeated observations and a new order for adaptive equipment was an assessment conducted, which confirmed the resident would benefit from items such as a plate guard, sippie cup, and weighted utensils.