Failure to Assist Resident with ADLs During Meals
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically eating, to a resident with significant impairments. The resident in question was legally blind, had left side hemiparesis, contractures in the left elbow and hand, and required substantial to maximal assistance to use utensils and consume meals. Despite care plans and physician orders specifying the need for a divided plate, set-up, cueing, and assistance during meals, the resident was repeatedly observed eating with his hands due to lack of staff support. Staff did not provide the required divided plate or adaptive utensils, and the resident reported being left to feed himself despite his inability to hold utensils or see his food. Multiple observations confirmed that staff failed to assist or cue the resident during meals, resulting in the resident using his hands and experiencing difficulty and mess while eating. Interviews with the resident, staff, and therapy personnel confirmed the lack of consistent assistance and the absence of required adaptive equipment. The resident had filed grievances about not receiving help, and staff acknowledged that assistance was inconsistent, sometimes due to turnover in dietary management. The occupational therapist confirmed the resident required 1:1 assistance and verbal cues during meals, and that the divided tray was not consistently provided as ordered. These failures directly contradicted the facility's own ADL policy and the resident's care plan, resulting in the resident not receiving necessary services to maintain good nutrition and dignity during meals.