Failure to Maintain Resident Dignity During Mealtime Assistance
Penalty
Summary
The facility failed to ensure that two residents were treated with dignity during mealtimes. One resident with hemiplegia and hemiparesis, who was unable to use her left side and had severely impaired cognitive skills, was observed eating breakfast in bed without a clothing protector. This resulted in food and drink spilling onto her chest, neck, gown, tray, bedside table, and comforter. Staff interviews confirmed that a towel or similar item should have been placed to protect the resident and maintain her dignity during meals, but this was not done at the time of observation. Another resident, who had dementia, diabetes, and severe protein-calorie malnutrition, required substantial assistance with activities of daily living and was dependent for mobility. During a lunch meal, a treatment nurse was observed standing and leaning over the resident while providing feeding assistance, rather than sitting at eye level. The resident reported feeling rushed and uncomfortable when staff stood over her during meals, expressing a preference for staff to sit beside her, which made her feel more at ease. The nurse later acknowledged that sitting at eye level would have promoted dignity and comfort for the resident. Facility policy and staff interviews confirmed that the expectation was to uphold resident dignity during all aspects of care, including meal assistance. The policies reviewed emphasized providing a dignified dining experience and treating all residents with kindness, respect, and dignity. However, the observed actions did not align with these expectations, resulting in a failure to honor the residents' rights to a dignified existence and self-determination during mealtimes.