Failure to Provide Required Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide appropriate assistive eating devices to residents who required them, as identified through record review, observation, and staff interviews. Specifically, two residents with severe cognitive impairment and significant physical limitations, including hemiplegia, hemiparesis, and Parkinson's, were observed during meal times without the adaptive equipment prescribed in their care plans and physician orders. For one resident, a sippy cup with lid/spout and a divided plate were ordered and documented as necessary to promote independence with beverages, but the resident did not receive the sippy cup during meal observation. For the second resident, a two-handled sippy cup, built-up utensils, and a scoop plate were ordered, but the resident did not have the two-handled sippy cup at the time of observation. These deficiencies were confirmed by reviewing tray tickets and through verification with two CNAs present during meal service. The issue was identified during a complaint investigation and also had the potential to affect additional residents who were documented as needing adaptive equipment for eating and drinking. The findings were based on direct observation, medical record review, and staff interviews, with no evidence that the required adaptive devices were provided at the time of the survey.