Failure to Provide Ordered Weighted Utensils for Resident with Hand Tremors
Penalty
Summary
The facility failed to provide a resident with weighted utensils as ordered by the physician and outlined in the resident's care plan. The resident, who had diagnoses including parkinsonism, schizoaffective disorder, and major depressive disorder, was noted to have hand tremors and impaired upper extremity function, making self-feeding difficult. The resident's care plan and physician orders specifically required the use of adaptive feeding equipment, including a divided plate and weighted utensils, to support independence in eating. Observations on two separate occasions revealed that the resident received a weighted fork but was given a regular spoon and knife, despite the order for all utensils to be weighted. During these observations, the resident exhibited hand shaking while attempting to use the regular spoon, which made self-feeding challenging. Interviews with the Director of Rehab confirmed that the resident required weighted utensils to stabilize her hand and facilitate self-feeding, and that failure to provide these could result in the resident dropping food and becoming discouraged. The Dietary Supervisor acknowledged that the kitchen was responsible for providing the correct adaptive equipment as per physician orders and that the resident should have received weighted utensils for all meals. Review of facility policy confirmed that adaptive equipment is to be provided when recommended and that the dietary department is responsible for ensuring the correct equipment is distributed with meal trays.