Failure to Promote Dignified Dining Experience for Residents Requiring Assistance
Penalty
Summary
The facility failed to promote a dignified dining experience for six residents with severe cognitive impairments who required assistance with eating. Observations revealed that staff, including nursing assistants and an LPN, assisted these residents with meals while standing over them, rather than sitting at their level, and sometimes while performing other tasks. Residents who required feeding assistance were served their meals earlier than other residents and in a separate dinette area, rather than being given the option to eat in the main dining room with others. Staff interviews confirmed that this practice was implemented to make it easier for staff to manage meal service, rather than based on resident preference or choice. The affected residents had significant medical histories, including dementia, Alzheimer's disease, traumatic brain injury, and other cognitive or physical impairments, and their care plans directed staff to provide meal set-up and assistance as needed. Despite these directives, the facility's approach did not encourage resident choice or dignity, as most of the residents receiving early trays were unable to choose whether they would have preferred to eat in the main dining room. Facility policy required that residents be encouraged to eat in the dining room and be fed with attention to safety, comfort, and dignity, including not standing over residents while assisting with meals and avoiding the use of labels such as "feeders."