Failure to Provide Required Adaptive Dining Equipment
Penalty
Summary
The facility failed to provide adaptive dining equipment, specifically non-slip dycem, to two residents who required it for safe and independent eating, as indicated on their care plans and meal tray cards. Observations during breakfast meals revealed that both residents did not receive the dycem, although one did receive other adaptive utensils. Staff interviews indicated that one resident was no longer using dycem due to a change in feeding assistance needs, but the tray card had not been updated to reflect this change. The registered dietitian confirmed that she had not been informed of the updated equipment needs by the occupational therapy department, resulting in outdated tray card instructions. Medical record reviews for both residents showed documented needs for adaptive dining ware, including dycem, due to conditions such as cerebral palsy, visual impairment, osteoarthritis, dysphagia, dementia, and recent significant weight loss. The facility's policy required dietary staff to provide adaptive equipment as determined by the occupational therapist and to ensure it was placed on the resident's tray at each meal. Despite these documented needs and policies, the required adaptive equipment was not consistently provided, leading to increased difficulty with food consumption and independent eating for the affected residents.