Failure to Promote Dignity and Independence During Dining
Penalty
Summary
Two residents with significant medical needs, including multiple sclerosis, bilateral cataracts, severe protein deficiency malnutrition, and dysphagia, were not provided care in a manner that promoted their independence and dignity during mealtimes. Both residents were served plated meals on cafeteria trays while others at their table received their meals directly on the table with utensils. One resident was not properly positioned in a low-seated wheelchair, resulting in her shoulders being level with the edge of the dining table, and she struggled to identify and access food on her plate. Staff were observed standing over the residents to cut food and provide feeding assistance, while conversing with each other, rather than engaging with the residents. On another occasion, both residents were again improperly positioned at the table, struggled to eat independently, and ultimately left the dining room without eating their lunch, with no staff providing assistance during the meal. Interviews with facility staff, including a registered nurse and the director of nursing, confirmed that the residents should have been accommodated with appropriate tables and seating to enhance their ability to eat independently and maintain dignity and socialization. Facility policy also requires that staff avoid standing over residents while assisting them to eat and refrain from practices that ignore individual needs and preferences. The observed actions and inactions by staff failed to uphold these standards, resulting in a deficiency related to the residents' rights to dignity and independence during dining.