Failure to Promote Dignity During Mealtime Assistance
Penalty
Summary
A deficiency was identified when a certified nurse assistant (CNA) assisted a resident with dementia, sacral pressure ulcer, and heel pressure ulcers during mealtime while standing above the resident's eye level. The resident was dependent on staff for all activities of daily living, including eating, and had moderately impaired cognitive skills, requiring cues and supervision. The care plan for the resident specified that staff should assist at mealtime and with all food and fluid offerings. During the observed incident, the CNA stood on the right side of the bed and fed the resident from above, rather than sitting at eye level. This action was confirmed by a licensed vocational nurse (LVN) who verified that the CNA and the resident were not at the same eye level. The CNA explained that she did not sit because she was short and found it difficult to reach the resident from a seated position. Interviews with other nursing staff, including an LVN and a registered nurse (RN), confirmed that staff are expected to maintain eye level with residents during feeding to establish rapport and show respect. A review of the facility's policies indicated that residents should be cared for in a manner that promotes their sense of well-being, self-worth, and dignity, and that staff should not stand over residents while assisting them with meals. The observed practice did not align with these policies, resulting in a failure to promote dignity and respect for the resident during mealtime.
Plan Of Correction
Immediate Corrective Action for resident affected by this deficient practice: On 6/12/25, Administrator ordered 4 Height Adjustable Stools to provide to Staff to better assist them with providing meals to the residents in a dignified manner. Plan/Process to Identify other Residents potentially affected by same deficient Practice and Corrective Action(s) to be taken: On 6/13/25, DON did rounds with DSD and found 9 other residents who are assisted with meals by CNAs, all were observed sitting down at eye level and exchanging rapport and socializing in a dignified manner. Facility Measures and Systemic Changes to ensure the deficient practice does not reoccur: On 6/14/25, DSD in-serviced all CNAs regarding the importance of maintaining resident dignity while providing care. On 6/14/25, the DSD gave a 1:1 in-service to CNA 5 regarding the importance of sitting at eye level for Residents well being and dignity. Performance Monitoring: Starting 7/01/25, the DON or Designee will review check off form and findings will be reported to Administrator during our QAPI Monthly Meeting to ensure compliance is achieved. Monthly QAPI discussion will occur for 3 months. Facility Measures and Systemic Changes to ensure the deficient practice does not reoccur: On 6/14/25, DSD in-serviced all CNAs regarding the importance of maintaining resident dignity while providing care. On 6/14/25, the DSD gave a 1:1 in-service to CNA 5 regarding the importance of sitting at eye level for Residents well being and dignity. Performance Monitoring: Starting 7/01/25, the DON or Designee will review check off form and findings will be reported to Administrator during our QAPI Monthly Meeting to ensure compliance is achieved. Monthly QAPI discussion will occur for 3 months. F 550 Immediate Corrective Action: a. The plastic bag tying resident 33's closet was removed by the Maintenance Supervisor on 6/9/25.