Failure to Assess and Address Decline in Resident's Eating Ability
Penalty
Summary
A deficiency was identified when a resident experienced a decline in their ability to eat independently, moving from requiring only supervision and set-up help to needing extensive assistance from one staff member. The clinical record review showed that there was no documented evidence that the facility identified or assessed this decline in the resident's ability to perform the activity of daily living related to eating. Staff interviews confirmed that the decline was not assessed or addressed prior to the survey, and the facility was unable to provide any documentation showing that measures were implemented to mitigate the resident's loss of eating ability. The lack of assessment and intervention was confirmed by both the registered nurse assessment coordinator and facility leadership during the survey process.
Plan Of Correction
The facility identified the item noted, and Resident #12 has had a new screening for speech therapy completed and changes were implemented. No evidence or actual ill effects exist on any resident in our community due to lack of adherence to the requirements of activities of daily living. Education was conducted by the director of nursing or designee on MDS assessments and the process on how changes in condition should be documented, and interventions should be implemented to mitigate declines. Audits on five medical charts will be conducted to ensure compliance with appropriate assessments from identified findings weekly for one month and bi-weekly for three months. Findings will be presented to the Quality Assurance Performance Improvement committee for recommendations, an explanation of any identified variance infractions.