Failure to Provide Care-Planned Adaptive Eating Equipment
Penalty
Summary
A resident with moderate cognitive impairment and limited mobility, as identified in their quarterly MDS and care plan, required adaptive eating equipment—specifically, red foam handles for utensils—to promote independence and maintain personal hygiene during meals. During an observation, the resident was found eating in bed with regular metallic utensils, resulting in food spilled onto their chest. The meal tray and menu slip did not indicate the need for adaptive equipment, although a sign in the resident's room directed staff to use the red foam utensils. The adaptive equipment was found unused in the resident's bedside drawer, and the resident was eating without assistance. Interviews with staff, including a nursing assistant and the DON, confirmed that the red foam handles were care-planned and should have been used at all meals. The occupational therapist also verified the resident's need for the adaptive equipment and had communicated this to nursing. The medical record lacked documentation explaining why the adaptive utensils were not provided during the observed meal. Facility policy required that adaptive devices be noted on meal identification cards and care plans, and be provided as needed, but this was not followed in the resident's case.