Failure to Provide Required Adaptive Eating Equipment During Meals
Penalty
Summary
The facility failed to ensure that all residents requiring assistive eating devices had them available during meal times. Specifically, one resident with diagnoses including diabetes mellitus, respiratory failure with hypoxia, chronic kidney disease, heart failure, dysphagia, and other feeding difficulties, and who had intact cognition, did not receive the ordered adaptive equipment during breakfast. Physician orders and the resident's care plan specified the use of a divided plate, Kennedy cup, and built-up utensils for all meals as tolerated. However, during observation, the resident's breakfast tray only included regular utensils and Styrofoam cups with a lid and straw, and lacked the required Kennedy cup and built-up utensils. The resident confirmed during interview that she preferred and found it easier to use the Kennedy cup and built-up utensils, as these helped her eat and drink without making a mess. Review of the meal ticket on the tray also indicated that adaptive equipment was to be provided. An LPN verified that the resident was supposed to have the Kennedy cup and built-up utensils for all meals, and acknowledged that these were missing from the breakfast tray. Facility policy requires that adaptive devices be provided for residents who need or request them, but this was not followed in this instance.