Failure to Provide Adaptive Eating Utensils as Care Planned
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of rheumatoid arthritis, which affected her hand function, was not provided with adaptive eating utensils as specified in her care plan. Documentation, including the resident's care plan, nursing assistant care sheet, meal cards, and registered dietician notes, all indicated that built-up utensils were to be provided with every meal to assist with self-feeding. Despite these documented requirements, the resident reported not receiving the adaptive utensils for an extended period and was observed eating a meal without them, instead using her fingers to eat salad due to difficulty holding regular utensils. Interviews with facility staff, including an LPN and the registered nurse regional director, confirmed that the resident did not receive the required built-up silverware with her meal and that this was an ongoing issue despite previous education of dietary staff. The facility's policy required culinary staff to ensure the accuracy of tray assembly and the inclusion of all necessary utensils, but this was not followed in the resident's case.