Failure to Provide and Correctly Use Special Eating Equipment for Residents
Penalty
Summary
The facility failed to provide appropriate assistance and correct use of special eating equipment for two residents who required such devices. For one resident with generalized muscle weakness, dementia, and limited range of motion in both arms, the care plan and physician orders specified the use of a plate guard during meals to prevent food spillage and assist with self-feeding. However, during observation, the plate guard was positioned incorrectly, with the opening facing the resident, resulting in food spilling onto the table. Occupational therapy notes indicated that caregivers had been educated on the proper use and positioning of the plate guard, but this was not followed during the observed meal. Another resident, diagnosed with epilepsy and dementia, had a physician order and care plan specifying the use of a divided plate during meals due to potential nutritional problems. Instead, this resident was provided with a regular plate and a plate guard, which was also positioned incorrectly. Staff interviews confirmed that the assistive devices used were not correct for these residents and that improper use could result in food spillage. The facility's policy required staff to be trained and demonstrate competency in the use of assistive devices, but this was not adhered to during the observed incidents.