Failure to Provide Adaptive Eating Equipment as Ordered
Penalty
Summary
The facility failed to provide adaptive eating equipment as ordered for two residents with specific needs. One resident, with diagnoses including chronic kidney disease, dementia, failure to thrive, anemia, Alzheimer's disease, and weakness, had a physician's order and care plan indicating the use of built-up utensils. Despite this, the resident received regular utensils at both lunch and breakfast on multiple occasions, and reported not always receiving the larger silverware as required. Another resident, diagnosed with Parkinson's disease, femur fracture, irritable bowel syndrome, low back pain, muscle weakness, major depressive disorder, anxiety disorder, and weakness, had an active order for weighted utensils. This resident also received regular utensils instead of the prescribed adaptive equipment at several meals and stated that she does not always get the bigger silverware, though her sister wants her to use them. Dietary staff confirmed that kitchen staff are responsible for reading meal tickets and ensuring adaptive equipment is provided. Facility documentation also noted concerns about meal tickets being read incorrectly, resulting in residents not receiving appropriate items.