Failure to Document and Provide Required Eating Assistance
Penalty
Summary
The facility failed to ensure that a resident's care plan accurately reflected the required assistance and monitoring needed during meals. The resident in question had multiple diagnoses, including severely impaired cognition, and was documented as needing supervision or touching assistance with eating, as well as partial to full assistance with other activities of daily living. Despite these needs, the resident's care plan only addressed nutritional goals and meal monitoring, lacking specific instructions regarding the level of assistance and monitoring required while eating. Observations showed the resident eating alone in the dining room without staff present, struggling to access food on her plate. Interviews with staff revealed that information about residents' assistance needs was communicated verbally or through the Kardex, rather than being clearly documented in the care plan. Some staff were unsure if or how the required assistance should be reflected in the care plan, and the facility's policy required a comprehensive, person-centered care plan based on assessment findings.