Failure to Provide Dignified Dining Experience Due to Improper Table and Wheelchair Positioning
Penalty
Summary
Surveyors observed that two residents were not provided with a dignified dining experience during multiple meal services in the main dining room. Both residents were seated in wheelchairs that were significantly lower than the dining tables, resulting in their chins being at or below the tabletop. This positioning made it difficult for them to eat and required them to reach upward for their food and drinks. One resident was seen eating while hunched over and leaning to the right, and both had to lift their cups from below the table to drink. Staff interviews revealed that CNAs did not perceive the table height as a problem and were unsure if the tables could be adjusted. Neither resident had complained about the table height, and the ADON had not previously considered the issue. The clinical records for both residents indicated they were cognitively intact and required setup or clean-up assistance with eating. One resident had diagnoses including dementia, osteoarthritis, and heart failure, while the other had altered mental status, dysphagia, epilepsy, and adult failure to thrive. Care plans for both residents included supervision and assistance during meals, with interventions to ensure they were close enough to the table to reach food and drink properly. Facility policy stated that residents' needs and preferences should be honored as much as possible, considering their health status and safety.