Failure to Ensure Timely Meal Service and Maintain Dignity for Residents
Penalty
Summary
The facility failed to ensure that a resident was served a meal at the same time as her tablemate, resulting in the resident waiting 23 minutes for her breakfast while others at her table and surrounding tables ate their meals. Staff interviews revealed that although there was an attempt to serve all residents at a table simultaneously, the process was inconsistent, particularly when managing different diet consistencies. The affected resident had a care plan indicating risk for nutritional instability due to dementia, poor dentition, the need for a mechanically altered diet, and slow weight loss. Additionally, the facility did not maintain the dignity of a resident with a suprapubic catheter by failing to cover the catheter bag in public areas. Observations showed the resident's catheter bag was uncovered while she was seated in the dining room and day room, despite her care plan specifying that the catheter bag should be covered with a privacy bag. Staff confirmed that covers were available but were not used as required, resulting in a lack of privacy for the resident.