Failure to Ensure Dignified Dining Experience for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with severe unspecified dementia, anxiety, and bilateral cataracts was not treated with respect and dignity during mealtimes. The resident, who had highly impaired vision, severely impaired decision-making, and required supervision or assistance with eating, was observed eating alone in their room during multiple meals. The resident attempted to eat using a comb and a fork, resulting in food being spilled on themselves, the tray, the tray table, and the floor. The resident's care plan and Kardex indicated a need for continuous supervision during meals due to their cognitive and visual impairments, but this supervision was not provided. During one lunch observation, the resident was left alone and used a comb and fork to eat, leading to significant difficulty and mess. The resident was seen stabbing at food with the comb and fork, dropping food on the floor and themselves, and mixing chewed food with other meal items. The Activities Director discovered the resident in this state, located the proper eating utensil, and removed the comb, but the resident had already experienced a lack of dignity and appropriate assistance during the meal. Staff interviews revealed confusion about the resident's care needs, with the assigned CNA unaware of the specific requirements for supervision and the nurse confirming that the Kardex did require continuous supervision. Further observations showed the resident eating breakfast and lunch alone on other occasions, with food and drink being spilled due to lack of assistance. The Director of Nursing acknowledged that such incidents, including eating with a comb and spilling food, would be considered dignity concerns. The failure to provide the required supervision and appropriate utensils during meals resulted in the resident not being treated with the respect and dignity guaranteed by facility policy and federal and state laws.