Failure to Provide Ordered Plate Guard During Meals
Penalty
Summary
A resident with diagnoses including hemiplegia, hemiparesis, dysarthria, and adult failure to thrive was admitted to the facility and had a physician's order to use a plate guard during all meals. The resident's Minimum Data Set indicated intact cognition but dependence on staff for several activities of daily living. Despite the order, during an observation at mealtime, the resident was found eating without a plate guard, resulting in food spilling onto their blanket and clothes. The resident was observed picking up spilled food from their blanket and clothes while eating with their left hand. Interviews with a Licensed Vocational Nurse and the Director of Nursing confirmed that the resident should have been provided with a plate guard as ordered, to assist with scooping food and to prevent spillage. Review of the facility's policy indicated that residents recommended to use a plate guard should have it available and in place during meals. The failure to provide the ordered adaptive equipment constituted a deficiency in care.