Failure to Provide Specialized Eating Utensils as Indicated on Meal Tickets
Penalty
Summary
The facility failed to provide specialized eating utensils to two residents during a lunch meal, despite documentation indicating the need for such devices. One resident, admitted with severe protein-calorie malnutrition and dysphagia, was observed receiving a regular plate and utensils, although their meal ticket specified a scoop plate and built-up utensils. The second resident, also with severe protein-calorie malnutrition and muscle weakness, received regular utensils instead of the required built-up utensils as indicated on their meal ticket. Observations confirmed that the kitchen staff did not follow the meal ticket instructions for these residents. Interviews with the Dietary Supervisor and a Licensed Nurse revealed that staff were expected to provide assistive devices as indicated on meal tickets, and that the omission was not in accordance with facility policy or physician orders. The Licensed Nurse confirmed that one resident had a physician order and care plan for special utensils, while the other did not. The Registered Dietitian also stated that kitchen staff should have followed the meal ticket instructions. Facility policy required that residents needing self-feeding devices receive them with each meal, as recorded on tray cards and diet profiles.