Failure to Maintain Resident Dignity and Proper Assistance During Meals
Penalty
Summary
Surveyors identified that staff did not consistently promote or maintain resident dignity during mealtimes for several residents with significant cognitive and physical impairments. Multiple observations revealed that staff, including Certified Nursing Assistants and a trained feeding assistant, assisted residents with eating while standing over them rather than sitting beside them, contrary to facility policy. In some cases, staff provided only intermittent assistance, moving between multiple residents, which resulted in residents being left to attempt eating on their own despite documented needs for assistance. Residents with diagnoses such as dementia, dysphagia, and failure to thrive were observed struggling to eat independently, dropping food onto themselves and the floor, and using their hands or fingers to eat without staff intervention. For example, one resident with severe cognitive impairment and a care plan requiring one-on-one meal assistance was observed being handed utensils and left without further help, leading to food spillage and lack of intake. Another resident, also severely cognitively impaired and dependent on staff for eating, was only partially assisted as staff rotated between tables, leaving the resident without continuous support. Interviews with staff confirmed that they were aware of the requirement to sit while assisting residents with meals but cited staffing shortages as a reason for standing and assisting multiple residents at once. Facility policies reviewed by surveyors emphasized the importance of providing a dignified dining experience and feeding residents with attention to safety, comfort, and dignity, which was not consistently observed during the survey period.