Failure to Provide Bedtime Nourishing Snacks to Residents
Penalty
Summary
The facility failed to provide nourishing snacks at bedtime for all nine residents reviewed, despite having a policy that required light refreshments or snacks to be available between meals and overnight. Observations during the initial tour revealed that State Tested Nursing Aides (STNAs) were only offering ice to residents in the evening and did not inquire about snacks. During a Resident Council meeting, all residents present confirmed that they had not been offered snacks at bedtime. Several residents had medical conditions that made access to snacks particularly important, including diabetes mellitus, morbid obesity, and major depressive disorder. For example, one resident reported needing snacks to manage blood sugar levels due to insulin use, and another described experiencing symptoms of hypoglycemia and resorted to keeping snacks in her room because she could not rely on staff to provide them. Multiple residents were assessed as cognitively intact, while others had moderate cognitive impairment, indicating a range of abilities to request or obtain snacks independently. Interviews with staff, including STNAs, the Executive Chef, the DON, and the Administrator, revealed inconsistencies in the process for offering snacks. While staff stated that snacks were available 24/7 and that aides were responsible for offering them, residents reported not being offered snacks at bedtime. The facility's policy and staff expectations were not consistently followed, resulting in residents not receiving nourishing snacks as required.