Failure to Provide Prescribed Adaptive Eating Equipment
Penalty
Summary
A deficiency occurred when a resident with a history of dysphagia, obesity, and self-feeding difficulties was not provided with the prescribed adaptive eating equipment, specifically a scoop plate, as ordered by the physician and indicated on the care plan. The resident was observed being fed by staff using a regular plate instead of the adaptive equipment, despite the tray card and physician order specifying the need for a scoop plate. Staff interviews revealed a lack of awareness regarding the therapy recommendations and the physician's order for the scoop plate. The dietary aide confirmed that the resident previously received meals with a scoop plate, but the new order on the tray card was not matched with the actual provision of the equipment due to the absence of a requisition for purchase. Further review showed that the registered dietitian was unaware of the order and discovered that therapy had not submitted the necessary requisition to obtain the scoop plate. The facility's policy required adaptive equipment to be provided based on comprehensive assessment, but this process was not followed, resulting in the resident not receiving the prescribed adaptive device. The resident's medical record indicated multiple diagnoses, including acute respiratory failure, dysphagia, and muscle weakness, and the MDS assessment showed moderate cognitive impairment and a need for one-person assistance with ADLs.