Failure to Ensure Resident Dignity During Meal Service
Penalty
Summary
During a lunch meal service on the Memory Care unit, two residents were seated together in the dining room awaiting their meals. A nurse aide placed a sandwich in front of one resident and instructed them not to touch it because the other resident at the table had not yet received anything, then proceeded to serve another table. Despite the instruction, the resident picked up the sandwich, prompting the aide to remind them not to touch it. The resident explained they were just looking at the sandwich. The resident then consumed the sandwich while the other resident at the table watched and waited, as the hot lunch meal had not yet arrived. Later, the resident who had already eaten the sandwich was served a hot meal before the other resident, who continued to wait. The second resident did not receive their meal until after the first resident had finished eating both the sandwich and the hot meal. These events were observed and later reviewed with facility leadership.