Failure to Provide Adaptive Dining Equipment for Resident with Stroke History
Penalty
Summary
A resident with a history of stroke and impaired use of her dominant right arm was repeatedly not provided with the adaptive dining equipment specified in her care plan and physician's orders. Despite clear documentation on her meal tickets and in her care plan indicating the need for built up utensils, she was served regular silverware at multiple meals. Observations showed the resident struggling to handle standard utensils, resulting in awkward and insecure grips, slow eating, and multiple attempts to pick up food. The resident herself reported difficulty using regular utensils and stated that built up utensils would make eating easier. Interviews with staff, including the Dietary Manager, confirmed that the resident was supposed to receive built up utensils with all meals as ordered. The facility's policy also required culinary staff to provide adaptive equipment for residents who would benefit from their use. Despite these requirements, the resident was not provided with the necessary adaptive utensils during the observed meals, leading to ongoing difficulty with eating.