Failure to Provide Required Adaptive Utensils During Meals
Penalty
Summary
The facility failed to provide a resident with the required adaptive utensils during mealtimes, despite clear documentation in the care plan and physician orders indicating the need for built-up silverware and a two-handled cup to support self-feeding. The resident, who had diagnoses including left-sided hemiplegia, cerebral infarction, dysphagia, muscle weakness, cognitive communication disorder, reduced mobility, and muscle contractures, was observed eating multiple meals with standard utensils and a regular cup, while wearing wrist orthoses. Staff did not offer the adaptive equipment during these meals, and the resident was noted to have difficulty handling the utensils. Interviews with staff confirmed that they were expected to review care plans and dietary requirements before serving meals, and that information about special utensils was accessible to all staff. The facility's policy required screening and provision of adaptive equipment to improve resident independence and quality of care. Despite these expectations and policies, the resident did not receive the necessary adaptive utensils during observed meals, constituting a failure to implement the care plan and physician orders.